MEDICARE: THERESA SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1902498736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA SMITH

Provider Business Mailing Address
First Line	:	3538 BOUGAINVILLE RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5491
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3538 BOUGAINVILLE RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5491
Country	:	US
Telephone Number	:	619-437-2954
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2021
Last Update Date	:	02/03/2021

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Directions to “ THERESA SMITH ” Practice Location

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