Provider Demographics
NPI:1063508026
Name:SMITH, NICK E (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W MARCH LN
Mailing Address - Street 2:SUITE 318E
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-6500
Mailing Address - Country:US
Mailing Address - Phone:209-952-8804
Mailing Address - Fax:209-952-8845
Practice Address - Street 1:3031 W MARCH LN
Practice Address - Street 2:SUITE 318E
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6500
Practice Address - Country:US
Practice Address - Phone:209-952-8804
Practice Address - Fax:209-952-8845
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-4024656OtherTIN
CA26-4024656OtherTIN