Provider Demographics
NPI:1609109636
Name:SMITH, NICOLE ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELIZABETH
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 1:270 CAGNEY LN
Mailing Address - Street 2:APT 313
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 CAGNEY LN
Practice Address - Street 2:APT 313
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2673
Practice Address - Country:US
Practice Address - Phone:323-839-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist