Provider Demographics
NPI:1487170999
Name:SMITH, MICKEY DEAN (RDH)
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2013
Mailing Address - Country:US
Mailing Address - Phone:208-848-8308
Mailing Address - Fax:
Practice Address - Street 1:844 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2013
Practice Address - Country:US
Practice Address - Phone:208-848-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60778846124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist