Basic Information
| Provider Information | |||||||||
| NPI: | 1639472962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 548 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492040548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177843950 | ||||||||
| FaxNumber: | 5177832728 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 W HIGH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492032986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177849385 | ||||||||
| FaxNumber: | 5177870852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901012342 | MI | Y | Dental Providers | Dentist |
No ID Information.