=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487327219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW SMITH DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2021
-----------------------------------------------------
Last Update Date | 07/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19657 WA-410
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-780-7003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16306 107TH CT SE
-----------------------------------------------------
City | YELM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98597-7652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-481-1172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE61175335
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------