Healthcare Provider Details

I. General information

NPI: 1043900012
Provider Name (Legal Business Name): CHAD SMYLIE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 S SAN PEDRO ST
LOS ANGELES CA
90013-2102
US

IV. Provider business mailing address

522 S SAN PEDRO ST
LOS ANGELES CA
90013-2102
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-7999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: