MEDICARE: DR. MICHAEL J SMOLJAN DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1001820-15	WI
2	1223E0200X	Endodontics	2020012407	MO

General Provider Information

NPI Number	:	1598262263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J SMOLJAN DDS, MS

Provider Business Mailing Address
First Line	:	12221 SAINT CHARLES ROCK RD
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12221 SAINT CHARLES ROCK RD
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2502
Country	:	US
Telephone Number	:	314-656-6615
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	08/03/2021

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