Basic Information
| Provider Information | |||||||||
| NPI: | 1952396103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | SMITH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 638 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955361157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077864028 | ||||||||
| FaxNumber: | 7077869029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A92702 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1952396103 | 01 | CA | NATIONAL PROVIDER IDENTIFICATION | OTHER |