Provider Demographics
NPI:1538479464
Name:SMOOT, JUSTIN W (DIPL OM)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:W
Last Name:SMOOT
Suffix:
Gender:M
Credentials:DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1857
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-1857
Mailing Address - Country:US
Mailing Address - Phone:405-742-6168
Mailing Address - Fax:
Practice Address - Street 1:101 S RANDALL AVE
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5233
Practice Address - Country:US
Practice Address - Phone:580-225-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist