Basic Information
| Provider Information | |||||||||
| NPI: | 1811342595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BENNETT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 POND AVE APT 521 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024457117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485058591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 495 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021351007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177830500 | ||||||||
| FaxNumber: | 6177835514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2016 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A168177 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 292464 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.