Provider Demographics
NPI:1356360341
Name:SMITH, ROGER DANIEL (DC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DANIEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16052 BEACH BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3801
Mailing Address - Country:US
Mailing Address - Phone:714-848-8122
Mailing Address - Fax:714-848-2968
Practice Address - Street 1:16052 BEACH BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3801
Practice Address - Country:US
Practice Address - Phone:714-848-8122
Practice Address - Fax:714-848-2968
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28289111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28289Medicare ID - Type UnspecifiedCHIROPRACTOR