Provider Demographics
NPI:1164976635
Name:SMITH, MARIE
Entity Type:Individual
Prefix:DR
First Name:MARIE
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 1:1420 LINCOLN WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2360
Mailing Address - Country:US
Mailing Address - Phone:208-664-8528
Mailing Address - Fax:
Practice Address - Street 1:1420 LINCOLN WAY STE 200
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2360
Practice Address - Country:US
Practice Address - Phone:208-664-8528
Practice Address - Fax:208-667-0797
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD47831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice