Individual
DR. GLEN ALLEN SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS MS
Contact information
Practice address
4725 N CLOVERDALE RD, BOISE, ID 83713
(208) 323-4458
(208) 321-1706
Mailing address
869 E ANTILLES CRT, MERIDIAN, ID 83642
(208) 887-1718
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
D30360R
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6L271
BLUE CROSS ID
—
01
—
734506
UNITED CONCORDIA
—
Enumeration date
08/02/2006
Last updated
07/08/2007
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