Provider Demographics
NPI:1184769739
Name:BUNDY-SMITH, SHANDRA LOLITA (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANDRA
Middle Name:LOLITA
Last Name:BUNDY-SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19512 SEQUOIA AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-6825
Mailing Address - Country:US
Mailing Address - Phone:708-288-6295
Mailing Address - Fax:708-889-1066
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3556
Practice Address - Country:US
Practice Address - Phone:708-596-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013090A1223G0001X
IL0190237851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice