Provider Demographics
NPI:1720014814
Name:SMITH, DAN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SHERMAN LN
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-5724
Mailing Address - Country:US
Mailing Address - Phone:580-765-9973
Mailing Address - Fax:
Practice Address - Street 1:425 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1924
Practice Address - Country:US
Practice Address - Phone:580-765-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK212103TC0700X
OK525106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist