1336459783 NPI number — MRS. SANDRA E SMITH-DICKENS MED

Table of content: MRS. SANDRA E SMITH-DICKENS MED (NPI 1336459783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336459783 NPI number — MRS. SANDRA E SMITH-DICKENS MED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH-DICKENS
Provider First Name:
SANDRA
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336459783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 MORTON VILLAGE DRIVE APT. 406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-391-9333
Provider Business Mailing Address Fax Number:
671-983-0351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 MORTON STREET
Provider Second Line Business Practice Location Address:
JAMAICA PLAIN
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02130-3735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-391-9333
Provider Business Practice Location Address Fax Number:
617-983-0351
Provider Enumeration Date:
10/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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