Provider Demographics
NPI:1003501701
Name:SMITH, DORETHA JONES
Entity type:Individual
Prefix:
First Name:DORETHA
Middle Name:JONES
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 1:10291 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:KENBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:23944-4011
Mailing Address - Country:US
Mailing Address - Phone:434-312-1484
Mailing Address - Fax:
Practice Address - Street 1:10291 PLANK RD
Practice Address - Street 2:
Practice Address - City:KENBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:23944-4011
Practice Address - Country:US
Practice Address - Phone:434-312-1484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT69510507172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver