Provider Demographics
NPI:1215374277
Name:SMITH, ALEXANDRA BACON (DMD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:BACON
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 S MACARTHUR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5087
Mailing Address - Country:US
Mailing Address - Phone:217-698-1717
Mailing Address - Fax:217-698-7134
Practice Address - Street 1:2965 S MACARTHUR BLVD STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5087
Practice Address - Country:US
Practice Address - Phone:217-698-1717
Practice Address - Fax:217-698-7134
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist