Provider Demographics
NPI:1740624170
Name:SMITLEY, ANGIE
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:SMITLEY
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 1:1300 STEDMAN ST
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-6661
Mailing Address - Country:US
Mailing Address - Phone:907-228-0320
Mailing Address - Fax:907-228-0255
Practice Address - Street 1:1300 STEDMAN ST
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6661
Practice Address - Country:US
Practice Address - Phone:907-228-0320
Practice Address - Fax:907-228-0255
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2123124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist