Provider Demographics
NPI:1417010414
Name:SMITH, JO DENTON
Entity Type:Individual
Prefix:MS
First Name:JO
Middle Name:DENTON
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 1:311 DODSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6334
Mailing Address - Country:US
Mailing Address - Phone:432-683-1045
Mailing Address - Fax:
Practice Address - Street 1:311 DODSON AVENUE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6334
Practice Address - Country:US
Practice Address - Phone:432-683-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
505281OtherBCBS
0861380001Medicare ID - Type Unspecified