Provider Demographics
NPI:1750031514
Name:SMITH, DANIEL JAY
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 CEDAR PL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-1216
Mailing Address - Country:US
Mailing Address - Phone:253-314-4275
Mailing Address - Fax:
Practice Address - Street 1:603 CEDAR PL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-1216
Practice Address - Country:US
Practice Address - Phone:253-314-4275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program