Provider Demographics
NPI:1134127152
Name:SMALLWOOD, DENNIS A (DO)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:A
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SANILAC
Mailing Address - State:MI
Mailing Address - Zip Code:48469-9620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1184 CLEAVER RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-1143
Practice Address - Country:US
Practice Address - Phone:888-758-5709
Practice Address - Fax:888-490-5454
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDS0059822083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4582075Medicaid
MI4590694Medicaid
MI01-5-32-1087-5OtherBCBS PIN
MI4590685Medicaid
MI4582075Medicaid