Provider Demographics
NPI:1659499259
Name:SMITH, NICOLE CONNORS (DMD MSD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:CONNORS
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928
Mailing Address - Country:US
Mailing Address - Phone:707-584-7755
Mailing Address - Fax:707-584-5640
Practice Address - Street 1:1331 MEDICAL CENTER DR
Practice Address - Street 2:SUITE F
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928
Practice Address - Country:US
Practice Address - Phone:707-584-7755
Practice Address - Fax:707-584-5640
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics