Provider Demographics
NPI:1972042869
Name:SMITH, DALE
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
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 1:36578 TOWNSHIP ROAD 131
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:OH
Mailing Address - Zip Code:43844
Mailing Address - Country:US
Mailing Address - Phone:740-294-8963
Mailing Address - Fax:
Practice Address - Street 1:36578 TOWNSHIP ROAD 131
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:OH
Practice Address - Zip Code:43844-9544
Practice Address - Country:US
Practice Address - Phone:740-294-8963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1601672172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker