Provider Demographics
NPI:1215627500
Name:SMITH, STEPHANIE ANN MARIE (RDH, CDHC, BSDH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDH, CDHC, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E BOND ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-2056
Mailing Address - Country:US
Mailing Address - Phone:618-663-7178
Mailing Address - Fax:
Practice Address - Street 1:4241 IL-14
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist