Basic Information
| Provider Information | |||||||||
| NPI: | 1720167596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMORRA | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHMADEKE | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 568 | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971130568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033528657 | ||||||||
| FaxNumber: | 5033528658 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 N 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971139020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033598505 | ||||||||
| FaxNumber: | 5033598535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D8738 | OR | Y | Dental Providers | Dentist |
No ID Information.