Provider Demographics
NPI:1780621870
Name:SMITH, ANNA R (DMD)
Entity type:Individual
Prefix:DR
First Name:ANNA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:R
Other - Last Name:BRADSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1317 DADRIAN PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1686
Mailing Address - Country:US
Mailing Address - Phone:618-466-0733
Mailing Address - Fax:618-466-1433
Practice Address - Street 1:1317 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1686
Practice Address - Country:US
Practice Address - Phone:618-466-0733
Practice Address - Fax:618-466-1433
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190265341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice