Healthcare Provider Details

I. General information

NPI: 1568559961
Provider Name (Legal Business Name): ROBERT RALPH SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 W SUNSET BLVD SUITE 200
LOS ANGELES CA
90069-3701
US

IV. Provider business mailing address

9201 W SUNSET BLVD SUITE 200
LOS ANGELES CA
90069-3701
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-5775
  • Fax: 310-275-5454
Mailing address:
  • Phone: 310-273-5775
  • Fax: 310-275-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number21512
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: