MEDICARE: SMILE AVENUE FAMILY AND COSMETIC DENTISTRY

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

General Provider Information

NPI Number	:	1992414981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE AVENUE FAMILY AND COSMETIC DENTISTRY

Provider Business Mailing Address
First Line	:	519 W CHICAGO ST
Second Line	:
City	:	COLDWATER
State	:	MI
Zip	:	49036-1892
Country	:	US
Telephone Number	:	517-279-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	519 W CHICAGO ST
Second Line	:
City	:	COLDWATER
State	:	MI
Zip	:	49036-1892
Country	:	US
Telephone Number	:	517-279-7900
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MISTY JUSKUSKY
Credential	:
Telephone Number	:	615-878-1595

Provider Enumeration Date	:	11/17/2022
Last Update Date	:	11/17/2022

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