Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | DN014148 | GA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | DN014148 | GA |
NPI | 1336466028 |
---|---|
Provider Name | Glendon W Smalley III |
First Address | Dublin, GA 31021-5245 |
Second Address | Dublin, GA 31021 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2010 |
Last Update Date | 18/10/2019 |