Healthcare Provider Details

I. General information

NPI: 1902761976
Provider Name (Legal Business Name): KELLY ANN SMITH RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5095 RIFLE RIVER TRL
ALGER MI
48610-9327
US

IV. Provider business mailing address

2575 SHAFFER RD
BEAVERTON MI
48612-8419
US

V. Phone/Fax

Practice location:
  • Phone: 989-873-5152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902010457
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: