Healthcare Provider Details

I. General information

NPI: 1982606927
Provider Name (Legal Business Name): KEVIN DENNIS SMITH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 VALLEY VIEW DR STE 1
MOLINE IL
61265-6138
US

IV. Provider business mailing address

505 VALLEY VIEW DR STE 1
MOLINE IL
61265-6138
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-7919
  • Fax: 309-762-3261
Mailing address:
  • Phone: 309-762-7919
  • Fax: 309-762-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-4863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: