Provider Demographics
NPI:1952524902
Name:SMITH, JOHN (BS , DOM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS , DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4396 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6016
Mailing Address - Country:US
Mailing Address - Phone:505-758-2038
Mailing Address - Fax:
Practice Address - Street 1:251 LOWER LAS COLONIAS RD.
Practice Address - Street 2:
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:505-758-2038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#028171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist