Provider Demographics
NPI:1053681346
Name:SMITH, MISTY
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HWY 270 & 56 JCT
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884
Mailing Address - Country:US
Mailing Address - Phone:405-257-7310
Mailing Address - Fax:405-257-2696
Practice Address - Street 1:HWY 270 & 56 JCT
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884
Practice Address - Country:US
Practice Address - Phone:405-257-7310
Practice Address - Fax:405-257-2696
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3022124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist