Healthcare Provider Details

I. General information

NPI: 1396896288
Provider Name (Legal Business Name): DR. RICK MARTIN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 N POWER RD SUITE 2
MESA AZ
85205-4909
US

IV. Provider business mailing address

1259 N POWER RD SUITE 2
MESA AZ
85205-4909
US

V. Phone/Fax

Practice location:
  • Phone: 480-832-4567
  • Fax: 480-854-3869
Mailing address:
  • Phone: 480-832-4567
  • Fax: 480-854-3869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number6366
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: