Provider Demographics
NPI:1174807929
Name:SMITH, LORI TRIEBEL (DDS)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:TRIEBEL
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 S COO Y YAH ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4624
Mailing Address - Country:US
Mailing Address - Phone:918-825-7645
Mailing Address - Fax:918-825-7646
Practice Address - Street 1:13 S COO Y YAH ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4624
Practice Address - Country:US
Practice Address - Phone:918-825-7645
Practice Address - Fax:918-825-7646
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100150130AMedicaid
OK$$$$$$$$$001OtherBLUE CROSS BLUE SHIELD OF OK