Provider Demographics
NPI:1043334600
Name:SMITH, MICHAEL T
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
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 1:466 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DENNIS PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02639-1319
Mailing Address - Country:US
Mailing Address - Phone:508-398-7723
Mailing Address - Fax:
Practice Address - Street 1:466 MAIN ST
Practice Address - Street 2:
Practice Address - City:DENNIS PORT
Practice Address - State:MA
Practice Address - Zip Code:02639-1319
Practice Address - Country:US
Practice Address - Phone:508-398-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110082344AMedicaid
MA1598392Medicaid