Provider Demographics
NPI:1013562644
Name:SMITH, BRENDAN MICHAEL (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 HACKETT HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-8993
Mailing Address - Country:US
Mailing Address - Phone:603-521-5659
Mailing Address - Fax:
Practice Address - Street 1:2014 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1607
Practice Address - Country:US
Practice Address - Phone:617-243-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4777133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered