Provider Demographics
NPI:1982089074
Name:CHACON-SMITH, LORENA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LORENA
Middle Name:
Last Name:CHACON-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 1:2491 WOODBURY ST
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-4801
Mailing Address - Country:US
Mailing Address - Phone:719-660-6312
Mailing Address - Fax:
Practice Address - Street 1:905 N GULF BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-3907
Practice Address - Country:US
Practice Address - Phone:281-824-1490
Practice Address - Fax:281-220-6407
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364193801Medicaid
TX53212ZHY5Medicare PIN