Healthcare Provider Details

I. General information

NPI: 1104858778
Provider Name (Legal Business Name): CONSTANCE ELIZABETH SMITH D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 HORTON RD SUITE #14
JACKSON MI
49203-5594
US

IV. Provider business mailing address

1931 HORTON RD SUITE #14
JACKSON MI
49203-5594
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-7520
  • Fax: 517-787-2575
Mailing address:
  • Phone: 517-787-7520
  • Fax: 517-787-2575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901012155
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: