Provider Demographics
NPI:1457837742
Name:SMITH, BRIAN G (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N RACINE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5465
Mailing Address - Country:US
Mailing Address - Phone:626-319-1165
Mailing Address - Fax:
Practice Address - Street 1:13033 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1718
Practice Address - Country:US
Practice Address - Phone:708-361-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204431122300000X
IL019.031658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist