=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134597446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAD SMART DDS AND VINCENT O KOKICH JR DMD MSD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 09/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2302 S UNION AVE STE B-14
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98405-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-752-3949
-----------------------------------------------------
Fax | 253-752-6392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2302 S UNION AVE STE B-14
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98405-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-752-3949
-----------------------------------------------------
Fax | 253-752-6392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHAD SMART
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 253-752-3949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DE00009092
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------