Healthcare Provider Details

I. General information

NPI: 1265176085
Provider Name (Legal Business Name): GROWING SMILES-ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51821 GRATIOT AVE
CHESTERFIELD MI
48051-2014
US

IV. Provider business mailing address

51821 GRATIOT AVE
CHESTERFIELD MI
48051-2014
US

V. Phone/Fax

Practice location:
  • Phone: 586-727-5500
  • Fax:
Mailing address:
  • Phone: 586-727-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TONI ANN COSTELLO
Title or Position: MANAGER
Credential:
Phone: 586-727-5500