Provider Demographics
NPI:1457129595
Name:SMITH, MAIA ROSE (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:MAIA
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 BOSTON POST RD UNIT 163
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1969
Mailing Address - Country:US
Mailing Address - Phone:860-912-8079
Mailing Address - Fax:
Practice Address - Street 1:310 BOSTON POST RD UNIT 163
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1969
Practice Address - Country:US
Practice Address - Phone:860-912-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2414133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered