Healthcare Provider Details

I. General information

NPI: 1053269076
Provider Name (Legal Business Name): GRETA MARY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LONGWOOD AVE
BOSTON MA
02115-5711
US

IV. Provider business mailing address

52 TEMPLE ST APT 8
BOSTON MA
02114-4230
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLDN8294
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: