Provider Demographics
NPI:1710572904
Name:SMITH, DALLAS MARIE
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 NE 104TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-5761
Mailing Address - Country:US
Mailing Address - Phone:360-281-3576
Mailing Address - Fax:
Practice Address - Street 1:2924 FALK RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-5604
Practice Address - Country:US
Practice Address - Phone:360-690-3069
Practice Address - Fax:360-726-5961
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61130502175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist