Healthcare Provider Details

I. General information

NPI: 1164567335
Provider Name (Legal Business Name): STEPHEN FREDERICK SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 BRUNSWICK RD SUITE 1
GRASS VALLEY CA
95945-9544
US

IV. Provider business mailing address

563 BRUNSWICK RD SUITE 1
GRASS VALLEY CA
95945-9544
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-4442
  • Fax: 530-272-3042
Mailing address:
  • Phone: 530-273-4442
  • Fax: 530-272-3042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD21407
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: