1821102765 NPI number — DALE WAYNE SMITH PT

Table of content: DALE WAYNE SMITH PT (NPI 1821102765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821102765 NPI number — DALE WAYNE SMITH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
DALE
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1821102765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670846
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75367-0846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-695-8847
Provider Business Mailing Address Fax Number:
214-368-0653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12404 PARK CENTRAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 150S
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-695-8847
Provider Business Practice Location Address Fax Number:
214-368-0653
Provider Enumeration Date:
08/18/2006

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: 2251X0800X , with the licence number:  1036424 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 83367T . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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