MEDICARE: DR. JAMIE LYNN SMITH D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	021002311	IL
2	122300000X	Dentist	01927346	IL

General Provider Information

NPI Number	:	1093926768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE LYNN SMITH D.D.S., M.S.

Provider Business Mailing Address
First Line	:	11013 N ONYX LN
Second Line	:
City	:	DUNLAP
State	:	IL
Zip	:	61525-9579
Country	:	US
Telephone Number	:	309-243-8359
Fax Number	:

Provider Business Practice Location Address
First Line	:	4207 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-685-4444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	08/22/2013

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