Healthcare Provider Details

I. General information

NPI: 1265952808
Provider Name (Legal Business Name): TIMOTHY PATRICK SMITH MS, RD, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2017
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 DAVIDSON GATEWAY DRIVE, SUITE 150-I
DAVIDSON NC
28036
US

IV. Provider business mailing address

207 MADELIA PLACE
MOORESVILLE NC
28115
US

V. Phone/Fax

Practice location:
  • Phone: 954-803-8533
  • Fax: 704-664-9075
Mailing address:
  • Phone: 954-803-8533
  • Fax: 704-664-9075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL005214
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: