Provider Demographics
NPI:1033700562
Name:SMITH, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11680 S 153RD WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-8564
Mailing Address - Country:US
Mailing Address - Phone:918-639-4684
Mailing Address - Fax:918-512-6320
Practice Address - Street 1:11680 S 153RD WEST AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-8564
Practice Address - Country:US
Practice Address - Phone:918-639-4684
Practice Address - Fax:918-512-6320
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner