Provider Demographics
NPI:1659736056
Name:SMITH, JENNIFER LEE (D160128721)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:D160128721
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8102 48TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-4406
Mailing Address - Country:US
Mailing Address - Phone:206-497-1986
Mailing Address - Fax:
Practice Address - Street 1:3626 FACTORIA BLVD SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-6128
Practice Address - Country:US
Practice Address - Phone:425-747-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD160128721126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAD160128721OtherRDA