MEDICARE: DR. NICOLE ALEXANDRA SMITH DMD

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	1223P0700X	Prosthodontics	019.027690	IL
2	122300000X	Dentist	019.027690	IL

General Provider Information

NPI Number	:	1780845511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE ALEXANDRA SMITH DMD

Provider Business Mailing Address
First Line	:	1615 TRUEMPER ST
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5511
Country	:	US
Telephone Number	:	210-292-0123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1615 TRUEMPER ST
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5511
Country	:	US
Telephone Number	:	210-292-0123
Fax Number	:

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

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	05/29/2025

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