Provider Demographics
NPI:1417620998
Name:SMITHCARE: GENERAL DERMATOLOGY, MOHS SURGERY & AESTHETICS PLLC
Entity Type:Organization
Organization Name:SMITHCARE: GENERAL DERMATOLOGY, MOHS SURGERY & AESTHETICS PLLC
Other - Org Name:SMITHCARE: DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-291-5700
Mailing Address - Street 1:21800 MARKET PL NW STE 103
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6667
Mailing Address - Country:US
Mailing Address - Phone:360-291-5700
Mailing Address - Fax:360-291-5702
Practice Address - Street 1:21800 MARKET PL NW STE 103
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6667
Practice Address - Country:US
Practice Address - Phone:360-291-5700
Practice Address - Fax:360-291-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty