Basic Information
| Provider Information | |||||||||
| NPI: | 1265153712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ELLSWORTH | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27000 W LUGONIA AVE APT 11216 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923742095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492829142 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2878 CAMPUS PKWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925070945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515710011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2022 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 107829 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.