Healthcare Provider Details

I. General information

NPI: 1659736056
Provider Name (Legal Business Name): JENNIFER LEE SMITH D160128721
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 FACTORIA BLVD SE
BELLEVUE WA
98006-6128
US

IV. Provider business mailing address

8102 48TH AVE S
SEATTLE WA
98118-4406
US

V. Phone/Fax

Practice location:
  • Phone: 425-747-4695
  • Fax:
Mailing address:
  • Phone: 206-497-1986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD160128721
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: