Provider Demographics
NPI:1073203915
Name:SMITH, DALE A II
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:SMITH
Suffix:II
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 1:2244 S WESTERN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-1305
Mailing Address - Country:US
Mailing Address - Phone:562-285-8642
Mailing Address - Fax:
Practice Address - Street 1:888 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2866
Practice Address - Country:US
Practice Address - Phone:310-396-2838
Practice Address - Fax:310-396-0578
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA183033183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician