Provider Demographics
NPI:1417915620
Name:SMITH, BRENT EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 EWALD AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3403
Mailing Address - Country:US
Mailing Address - Phone:503-378-0068
Mailing Address - Fax:503-378-0069
Practice Address - Street 1:705 EWALD AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3403
Practice Address - Country:US
Practice Address - Phone:503-378-0068
Practice Address - Fax:503-378-0069
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU90610Medicare UPIN
ORR113404Medicare ID - Type Unspecified