1871698134 NPI number — DR. STACY G SMITH DMD

Table of content: DR. STACY G SMITH DMD (NPI 1871698134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871698134 NPI number — DR. STACY G SMITH DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
STACY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
N/A
Provider Other First Name:
N/A
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1871698134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 HIGHWAY 314
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-7813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-460-6060
Provider Business Mailing Address Fax Number:
770-461-0541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 HIGHWAY 314
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-460-6060
Provider Business Practice Location Address Fax Number:
770-461-0541
Provider Enumeration Date:
09/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  11268 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)