Healthcare Provider Details

I. General information

NPI: 1215627500
Provider Name (Legal Business Name): STEPHANIE ANN MARIE SMITH RDH, CDHC, BSDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 IL-14
CHRISTOPHER IL
62822
US

IV. Provider business mailing address

410 E BOND ST
BENTON IL
62812-2056
US

V. Phone/Fax

Practice location:
  • Phone: 618-724-2401
  • Fax:
Mailing address:
  • Phone: 618-663-7178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: