Provider Demographics
NPI:1154998201
Name:SMITH, RUBY MARINA (DMD)
Entity type:Individual
Prefix:DR
First Name:RUBY
Middle Name:MARINA
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 PRUDDEN ST UNIT 222
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-5388
Mailing Address - Country:US
Mailing Address - Phone:517-614-3959
Mailing Address - Fax:
Practice Address - Street 1:933 3 MILE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1673
Practice Address - Country:US
Practice Address - Phone:616-784-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist