Healthcare Provider Details

I. General information

NPI: 1376163345
Provider Name (Legal Business Name): SMILE DOCTORS OF MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13945 PANTHER DR
DEWITT MI
48820-8506
US

IV. Provider business mailing address

PO BOX 674441
DALLAS TX
75267-4441
US

V. Phone/Fax

Practice location:
  • Phone: 517-669-5833
  • Fax:
Mailing address:
  • Phone: 254-727-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GREGORY GOGGANS
Title or Position: PRESIDENT
Credential: DMD
Phone: 254-727-3131