Provider Demographics
NPI:1174065304
Name:SMITH, D
Entity type:Individual
Prefix:MS
First Name:D
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57899 W RHODES AVE
Mailing Address - Street 2:
Mailing Address - City:DATELAND
Mailing Address - State:AZ
Mailing Address - Zip Code:85333-5540
Mailing Address - Country:US
Mailing Address - Phone:623-256-3963
Mailing Address - Fax:
Practice Address - Street 1:57899 W RHODES AVE
Practice Address - Street 2:
Practice Address - City:DATELAND
Practice Address - State:AZ
Practice Address - Zip Code:85333-5540
Practice Address - Country:US
Practice Address - Phone:623-256-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 332B00000X
AZSMITHDANG411332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171W00000XOther Service ProvidersContractor
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment