Healthcare Provider Details

I. General information

NPI: 1689888158
Provider Name (Legal Business Name): KEVIN J SMITH DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 NE 117TH AVE
VANCOUVER WA
98662-1504
US

IV. Provider business mailing address

10001 NE 117TH AVE
VANCOUVER WA
98662-1504
US

V. Phone/Fax

Practice location:
  • Phone: 360-944-9800
  • Fax:
Mailing address:
  • Phone: 360-944-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60171756
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00007532
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00010195
License Number StateWA

VIII. Authorized Official

Name: MRS. TIFFANY SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-944-9800