Provider Demographics
NPI:1811990252
Name:SMITH, DEAN T (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 SHORE HAVEN DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2257
Mailing Address - Country:US
Mailing Address - Phone:616-479-8936
Mailing Address - Fax:
Practice Address - Street 1:391 SHORE HAVEN DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2257
Practice Address - Country:US
Practice Address - Phone:616-479-8936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028094208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4471960Medicaid
MIB44452Medicare UPIN
MI0D16184Medicare PIN