Healthcare Provider Details

I. General information

NPI: 1548568405
Provider Name (Legal Business Name): STEPHEN E. SMITH DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 YELM AVE W STE 3
YELM WA
98597-8764
US

IV. Provider business mailing address

PO BOX 1090
YELM WA
98597-1090
US

V. Phone/Fax

Practice location:
  • Phone: 360-458-5606
  • Fax:
Mailing address:
  • Phone: 360-458-5606
  • Fax: 360-458-1948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00004942
License Number StateWA

VIII. Authorized Official

Name: STEPHEN E SMITH
Title or Position: OWNER
Credential: DMD
Phone: 360-458-5606