Provider Demographics
NPI:1437205887
Name:SMITH-EDWARDS, JULIET V
Entity type:Individual
Prefix:
First Name:JULIET
Middle Name:V
Last Name:SMITH-EDWARDS
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 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-583-1800
Mailing Address - Fax:
Practice Address - Street 1:111 COORS BLVD NW
Practice Address - Street 2:E-6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-2006
Practice Address - Country:US
Practice Address - Phone:505-352-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD25501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59325771Medicaid
NM961058OtherUNITED CONCORDIA
NM0015438OtherDORAL