Healthcare Provider Details

I. General information

NPI: 1215061502
Provider Name (Legal Business Name): KRISTEN SMITH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5876 KINGSTOWNE CTR SUITE 150
ALEXANDRIA VA
22315-5735
US

IV. Provider business mailing address

5876 KINGSTOWNE CTR SUITE 150
ALEXANDRIA VA
22315-5735
US

V. Phone/Fax

Practice location:
  • Phone: 703-417-9316
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000919
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: