Healthcare Provider Details

I. General information

NPI: 1740721810
Provider Name (Legal Business Name): KRISTINE ANNE SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/06/2022
Certification Date: 03/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR OTOLARYNGOLOGY/ENT, CLINIC 9
SALT LAKE CITY UT
84132
US

IV. Provider business mailing address

2110 BOWNESS RD NW
CALGARY AB
T2N3L1
CA

V. Phone/Fax

Practice location:
  • Phone: 801-587-8368
  • Fax:
Mailing address:
  • Phone: 587-228-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number10222696-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number10222696-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: