Active NPI
Ethan J Smith, DDS
- General Practice Dentistry
- Waterloo, IA
National Provider Identifier
1053206672
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 10363
- Practice address
- 4031 Bankers Blvd
Waterloo, IA 50701-7900 - Phone
- (319) 232-9023
- NPI assigned
- Jun 12, 2025
- Sex
- Unspecified or another gender identity
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 10363 | IA | Primary |
Addresses
Primary practice location
4031 Bankers Blvd
Waterloo, IA 50701-7900
Mailing address
4031 Bankers Blvd
Waterloo, IA 50701-7900
Phone (319) 232-9023
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10363 | IA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1749686400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1750550400000",
"number": "1053206672",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4031 BANKERS BLVD",
"city": "WATERLOO",
"state": "IA",
"postal_code": "507017900",
"telephone_number": "319-232-9023"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4031 BANKERS BLVD",
"city": "WATERLOO",
"state": "IA",
"postal_code": "507017900",
"telephone_number": "319-232-9023"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SMITH",
"first_name": "ETHAN",
"middle_name": "J",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "X",
"enumeration_date": "2025-06-12",
"last_updated": "2025-06-22",
"certification_date": "2025-06-22",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "IA",
"license": "10363",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Waterloo, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 22, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.