Provider Demographics
NPI:1235346594
Name:SMITH, JUSTIN RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RICHARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 ALDER ST
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282-8672
Mailing Address - Country:US
Mailing Address - Phone:360-657-1650
Mailing Address - Fax:360-657-1502
Practice Address - Street 1:3710 168TH ST NE
Practice Address - Street 2:SUITE B-105
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8461
Practice Address - Country:US
Practice Address - Phone:360-657-1650
Practice Address - Fax:360-657-1502
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19026756122300000X
WADE 109141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5054846Medicaid