Provider Demographics
NPI:1174796247
Name:SMITH, MONIQUE DASE (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:DASE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:CHANTRELL
Other - Last Name:DASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:122 1ST AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4871
Mailing Address - Country:US
Mailing Address - Phone:907-459-3800
Mailing Address - Fax:
Practice Address - Street 1:1717 W COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5926
Practice Address - Country:US
Practice Address - Phone:907-459-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000487502084P0800X
390200000X
AK76672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1600801Medicaid