Provider Demographics
NPI:1225478936
Name:SMITH, CICELY BROOKE (DDS)
Entity Type:Individual
Prefix:
First Name:CICELY
Middle Name:BROOKE
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 1:8520 SHERWOOD DR
Mailing Address - Street 2:APT. 3
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 S ELISEO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2023
Practice Address - Country:US
Practice Address - Phone:415-461-0414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA623991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry