Provider Demographics
NPI:1396892030
Name:SMITH, JERROLD WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W. 95TH. STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1116
Mailing Address - Country:US
Mailing Address - Phone:773-881-3910
Mailing Address - Fax:773-881-4058
Practice Address - Street 1:2000 W. 95TH. STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1116
Practice Address - Country:US
Practice Address - Phone:773-881-3920
Practice Address - Fax:773-881-4058
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120106851223G0001X
IL0190165841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019016584Medicaid