Healthcare Provider Details

I. General information

NPI: 1730881095
Provider Name (Legal Business Name): MIKAYLA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9445 STEVENS RD
SHREVEPORT LA
71106-7572
US

IV. Provider business mailing address

9445 STEVENS RD STE 120
SHREVEPORT LA
71106-7573
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-0493
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7664
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: