Healthcare Provider Details

I. General information

NPI: 1083605257
Provider Name (Legal Business Name): SID C SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E CLINTON AVE
MONMOUTH IL
61462-5710
US

IV. Provider business mailing address

119 E CLINTON AVE PO BOX 645
MONMOUTH IL
61462-5710
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-3611
  • Fax: 309-734-8080
Mailing address:
  • Phone: 309-734-3611
  • Fax: 309-734-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: