Provider Demographics
NPI:1730351891
Name:JERROLD W. SMITH D.D.S.P.C.
Entity type:Organization
Organization Name:JERROLD W. SMITH D.D.S.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-881-3910
Mailing Address - Street 1:2000 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1116
Mailing Address - Country:US
Mailing Address - Phone:773-881-3910
Mailing Address - Fax:773-881-4058
Practice Address - Street 1:2000 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1116
Practice Address - Country:US
Practice Address - Phone:773-881-3910
Practice Address - Fax:773-881-4058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003789Medicaid