Healthcare Provider Details

I. General information

NPI: 1982654257
Provider Name (Legal Business Name): STEPHEN DALE SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 FORT MISSOULA RD #115
MISSOULA MT
59804-7420
US

IV. Provider business mailing address

2825 FORT MISSOULA RD #115
MISSOULA MT
59804-7420
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-4292
  • Fax: 406-728-5770
Mailing address:
  • Phone: 406-728-4292
  • Fax: 406-728-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4309
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: