Healthcare Provider Details

I. General information

NPI: 1215029350
Provider Name (Legal Business Name): DANIEL C SMITH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 N US 23 SUITE 2
E TAWAS MI
48730
US

IV. Provider business mailing address

1691 N US 23 SUITE 2
E TAWAS MI
48730
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-9546
  • Fax: 989-362-9567
Mailing address:
  • Phone: 989-362-9546
  • Fax: 989-362-9567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003153
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: