Provider Demographics
NPI:1598170771
Name:SMIDT, PETER (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:SMIDT
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 1:1600 S 4TH AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2889
Mailing Address - Country:US
Mailing Address - Phone:309-263-2781
Mailing Address - Fax:
Practice Address - Street 1:1600 S 4TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2889
Practice Address - Country:US
Practice Address - Phone:309-263-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190298561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice