Healthcare Provider Details

I. General information

NPI: 1093123564
Provider Name (Legal Business Name): TOMAS DANTE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 E PALMDALE BLVD SUITE C
PALMDALE CA
93550-2000
US

IV. Provider business mailing address

1543 E PALMDALE BLVD SUITE C
PALMDALE CA
93550-2000
US

V. Phone/Fax

Practice location:
  • Phone: 661-274-1200
  • Fax: 661-274-1199
Mailing address:
  • Phone: 661-274-1200
  • Fax: 661-274-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number23564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: