Basic Information
Provider Information
NPI: 1033556923
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: DENNIS
MiddleName:  
NamePrefix:  
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Credential:  
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OtherLastName:  
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Mailing Information
Address1: 11905 S CENTRAL AVE
Address2: STE 204-205
City: LOS ANGELES
State: CA
PostalCode: 90059
CountryCode: US
TelephoneNumber: 3232499026
FaxNumber: 3232498367
Practice Location
Address1: 11905 S CENTRAL AVE
Address2: STE 204-205
City: LOS ANGELES
State: CA
PostalCode: 900592897
CountryCode: US
TelephoneNumber: 3232499026
FaxNumber: 3232498367
Other Information
ProviderEnumerationDate: 05/31/2013
LastUpdateDate: 05/31/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  Y Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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