Provider Demographics
NPI:1467702779
Name:SMITH, BREIGH BLACK (RDH)
Entity Type:Individual
Prefix:MS
First Name:BREIGH
Middle Name:BLACK
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3597 S PEARL ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3873
Mailing Address - Country:US
Mailing Address - Phone:720-556-3444
Mailing Address - Fax:
Practice Address - Street 1:3597 S PEARL ST STE 101
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3873
Practice Address - Country:US
Practice Address - Phone:720-556-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905519124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist