Healthcare Provider Details

I. General information

NPI: 1043248818
Provider Name (Legal Business Name): JACK DALE SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J. DALE SMITH JR. M.D.

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COTTONWOOD ST SUITE 302
WOODLAND CA
95695-5131
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 530-666-1631
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG37180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: