Provider Demographics
NPI:1518459072
Name:SMITH, SARA M (RDH)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:M
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 1:636 BROADWAY ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413
Mailing Address - Country:US
Mailing Address - Phone:612-746-1530
Mailing Address - Fax:612-746-1531
Practice Address - Street 1:636 BROADWAY ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413
Practice Address - Country:US
Practice Address - Phone:612-746-1530
Practice Address - Fax:612-746-1531
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH87211223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health