Provider Demographics
NPI:1144081167
Name:MCCLISH-SMITH, DYLAN JOHN
Entity type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:JOHN
Last Name:MCCLISH-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 1:4713 E VAN BUREN ST UNIT 2019
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-0003
Mailing Address - Country:US
Mailing Address - Phone:520-250-6603
Mailing Address - Fax:
Practice Address - Street 1:5040 E SHEA BLVD
Practice Address - Street 2:SUITE #164
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program