Provider Demographics
NPI:1780845511
Name:SMITH, NICOLE ALEXANDRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ALEXANDRA
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ALEXANDRA
Other - Last Name:VAZQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:307 WEST LOSEY ST
Mailing Address - Street 2:BLDG 1535
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225
Mailing Address - Country:US
Mailing Address - Phone:618-256-6667
Mailing Address - Fax:
Practice Address - Street 1:307 WEST LOSEY ST
Practice Address - Street 2:BLDG 1535
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-256-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027690122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist