Provider Demographics
NPI:1760600720
Name:LIESL BREDESON SMITH, M.D., P.A.
Entity Type:Organization
Organization Name:LIESL BREDESON SMITH, M.D., P.A.
Other - Org Name:LIESL B SMITH, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LIESL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-345-8485
Mailing Address - Street 1:PO BOX 678149
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8149
Mailing Address - Country:US
Mailing Address - Phone:214-345-8485
Mailing Address - Fax:214-345-8486
Practice Address - Street 1:8160 WALNUT HILL LN
Practice Address - Street 2:SUITE 212
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4339
Practice Address - Country:US
Practice Address - Phone:214-345-8485
Practice Address - Fax:214-345-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3012174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH30040Medicare UPIN
TX00485WMedicare PIN