Provider Demographics
NPI:1265952808
Name:SMITH, TIMOTHY PATRICK (MS, RD, LDN)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MADELIA PLACE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115
Mailing Address - Country:US
Mailing Address - Phone:954-803-8533
Mailing Address - Fax:704-664-9075
Practice Address - Street 1:630 DAVIDSON GATEWAY DRIVE, SUITE 150-I
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036
Practice Address - Country:US
Practice Address - Phone:954-803-8533
Practice Address - Fax:704-664-9075
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-25
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered