Provider Demographics
NPI:1407589807
Name:SMITH, NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
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 1:2107 GRAND BLVD APT 909
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-1880
Mailing Address - Country:US
Mailing Address - Phone:785-231-8047
Mailing Address - Fax:
Practice Address - Street 1:3901 S BOLGER RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6779
Practice Address - Country:US
Practice Address - Phone:816-708-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022025258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist