Provider Demographics
NPI:1588654354
Name:SMITH, ROAUL DIETRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:ROAUL
Middle Name:DIETRICK
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 1:9015 13TH ST NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258
Mailing Address - Country:US
Mailing Address - Phone:425-397-6881
Mailing Address - Fax:
Practice Address - Street 1:1666 E. OLIVE WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102
Practice Address - Country:US
Practice Address - Phone:206-323-1666
Practice Address - Fax:206-323-6639
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034502111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor