1861591679 NPI number — DANE E. SMITH DDS PC

Table of content: (NPI 1861591679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861591679 NPI number — DANE E. SMITH DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANE E. SMITH DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861591679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97459-1108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-756-3683
Provider Business Mailing Address Fax Number:
541-756-1974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
565 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-9702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-469-5373
Provider Business Practice Location Address Fax Number:
541-412-0177
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DANE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-756-3683

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  D4773 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 164848 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: D4773 . This is a "DENTAL LICENSE #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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