Provider Demographics
NPI:1326089434
Name:SMITH, DEAN LAVERN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:LAVERN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 NW KINGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 E ST NW
Practice Address - Street 2:OFFICE OF MEDICAL SERVICES; US DEPARTMENT OF STATE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20522-0001
Practice Address - Country:US
Practice Address - Phone:202-663-1680
Practice Address - Fax:202-663-1717
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE60621Medicare UPIN