Provider Demographics
NPI:1164595195
Name:SMITH, NANCY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 SHERMER RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-4581
Mailing Address - Country:US
Mailing Address - Phone:847-272-0073
Mailing Address - Fax:847-272-2138
Practice Address - Street 1:1356 SHERMER RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4581
Practice Address - Country:US
Practice Address - Phone:847-272-0073
Practice Address - Fax:847-272-2138
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL102702Medicaid
IL1004878Medicaid
IL102630Medicaid