1356085930 NPI number — SMILIE'S PEDIATRIC DENTISTRY

Table of content: (NPI 1356085930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356085930 NPI number — SMILIE'S PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILIE'S PEDIATRIC DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356085930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2017 EASTCASTLE DRIVE SE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49508-8872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-455-4646
Provider Business Mailing Address Fax Number:
616-455-6024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2017 EASTCASTLE DRIVE SE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49508-8872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-455-4646
Provider Business Practice Location Address Fax Number:
616-455-6024
Provider Enumeration Date:
04/21/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LADUE
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
616-455-4646

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com