Healthcare Provider Details

I. General information

NPI: 1861785586
Provider Name (Legal Business Name): CHERYL ANN SMITH RDH-EP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MIRA MAR AVE
MEDFORD OR
97504-8546
US

IV. Provider business mailing address

711 MEDFORD CTR # 392
MEDFORD OR
97504-6772
US

V. Phone/Fax

Practice location:
  • Phone: 541-282-4014
  • Fax: 866-775-1369
Mailing address:
  • Phone: 541-282-4014
  • Fax: 866-775-1369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5368
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: