Basic Information
| Provider Information | |||||||||
| NPI: | 1629276175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHMIDT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 839 W CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207299890 | ||||||||
| FaxNumber: | 5208849287 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 W CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206703758 | ||||||||
| FaxNumber: | 5206703759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 07/19/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 03614 | WV | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 5758 | AZ | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 739807 | 05 | AZ | MEDICAID |