Basic Information
| Provider Information | |||||||||
| NPI: | 1831175769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 WOODBERRY DR | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308094456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165068432 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | BLDG 38801 ACADEMIC DR | ||||||||
| Address2: | SUITE B & C | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2675 | NM | Y | Dental Providers | Dentist | General Practice |
No ID Information.