Provider Demographics
NPI:1942461371
Name:SMITH, TERESA LEE (RADIOLOGY TECH)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RADIOLOGY TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:605-867-3083
Mailing Address - Fax:605-867-3364
Practice Address - Street 1:EAST HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770
Practice Address - Country:US
Practice Address - Phone:605-867-3083
Practice Address - Fax:605-867-3364
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3678152471C3402X, 2471M2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography