Provider Demographics
NPI:1871603803
Name:SMITH, GARY E (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111
Mailing Address - Country:US
Mailing Address - Phone:812-256-2143
Mailing Address - Fax:812-256-0420
Practice Address - Street 1:1417 MARKET ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111
Practice Address - Country:US
Practice Address - Phone:812-256-2143
Practice Address - Fax:812-256-0420
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
J644290OtherBCBS