Provider Demographics
NPI:1316678006
Name:SMITH, DOMINIC JOSEPH
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MONROE 6782
Mailing Address - Street 2:
Mailing Address - City:LAS CONDES
Mailing Address - State:SANTIAGO
Mailing Address - Zip Code:7550000
Mailing Address - Country:CL
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:903 BRIGHTSEAT RD
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4725
Practice Address - Country:US
Practice Address - Phone:301-333-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD273581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD27358OtherMARYLAND BOARD OF SOCIAL WORK EXAMINERS