Provider Demographics
NPI:1134500770
Name:SMITH, DENA LOU (MD FACS)
Entity Type:Individual
Prefix:MS
First Name:DENA
Middle Name:LOU
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD FACS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:615 BLACK RIDGE LANE
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444
Mailing Address - Country:US
Mailing Address - Phone:805-929-5220
Mailing Address - Fax:805-929-5220
Practice Address - Street 1:615 BLACK RIDGE LANE
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444
Practice Address - Country:US
Practice Address - Phone:805-929-5220
Practice Address - Fax:805-929-5220
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA-20644208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery