Provider Demographics
NPI:1366520827
Name:SMITH, MARK ELLSWORTH (DDS PC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLSWORTH
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 E. GALA ST.
Mailing Address - Street 2:200
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4880
Mailing Address - Country:US
Mailing Address - Phone:208-846-8847
Mailing Address - Fax:208-288-0786
Practice Address - Street 1:2320 E GALA ST
Practice Address - Street 2:200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7091
Practice Address - Country:US
Practice Address - Phone:208-846-8847
Practice Address - Fax:208-288-0786
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-14631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice