Provider Demographics
NPI:1124682497
Name:SMIDT, GRETA R
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:R
Last Name:SMIDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11936 DARLINGTON AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5651
Mailing Address - Country:US
Mailing Address - Phone:229-251-7570
Mailing Address - Fax:
Practice Address - Street 1:413 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-7801
Practice Address - Country:US
Practice Address - Phone:229-269-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7282122300000X
FLDN245431223P0700X
390200000X
CA1082571223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program