Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019030333 | IL |
NPI | 1003955436 |
---|---|
Provider Name | Dr. Michael Smith |
First Address | Oak Lawn, IL 60453-2382 |
Second Address | Oak Lawn, IL 60453-2382 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 11/02/2022 |