Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | D-3549-OR | ID |
NPI | 1013920313 |
---|---|
Provider Name | Dr. Samuel G. Smith |
First Address | Boise, ID 83709 |
Second Address | Boise, ID 83709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2006 |
Last Update Date | 08/07/2007 |