Provider Demographics
NPI:1306361316
Name:SMITH, KACHINA LIA (DAC)
Entity Type:Individual
Prefix:DR
First Name:KACHINA
Middle Name:LIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2841
Mailing Address - Country:US
Mailing Address - Phone:301-580-1411
Mailing Address - Fax:
Practice Address - Street 1:7750 MONTPELIER RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-6010
Practice Address - Country:US
Practice Address - Phone:612-888-7721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02383171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty