Provider Demographics
NPI:1669257226
Name:PANDA, SMITARANI
Entity type:Individual
Prefix:
First Name:SMITARANI
Middle Name:
Last Name:PANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 S WABASH AVE APT 1510
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2330
Mailing Address - Country:US
Mailing Address - Phone:917-631-2193
Mailing Address - Fax:
Practice Address - Street 1:1264A N LAKE ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-2453
Practice Address - Country:US
Practice Address - Phone:630-801-9028
Practice Address - Fax:630-801-9053
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2025-09-03
Deactivation Date:2024-04-03
Deactivation Code:
Reactivation Date:2025-09-03
Provider Licenses
StateLicense IDTaxonomies
IL019.036379122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program