Provider Demographics
NPI:1720052996
Name:SMITH, MICHAEL DEAN (NBC HIS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:NBC HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:612-351-1529
Mailing Address - Fax:
Practice Address - Street 1:100 S WILSON AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129
Practice Address - Country:US
Practice Address - Phone:515-386-2443
Practice Address - Fax:515-233-1012
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA237600000X
IA496237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter