Healthcare Provider Details

I. General information

NPI: 1720975907
Provider Name (Legal Business Name): LAURIE SMALLEY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 NEW YORK RANCH RD
JACKSON CA
95642-9407
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-2460
  • Fax: 209-257-2464
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number14446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: