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 1:1615 TRUEMPER ST
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5511
Mailing Address - Country:US
Mailing Address - Phone:210-292-0123
Mailing Address - Fax:
Practice Address - Street 1:1615 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5511
Practice Address - Country:US
Practice Address - Phone:210-292-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0276901223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist