Healthcare Provider Details

I. General information

NPI: 1235950890
Provider Name (Legal Business Name): GALLERY B SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 DELTA AVE
GLADSTONE MI
49837-1438
US

IV. Provider business mailing address

1709 LAKE SHORE DR
ESCANABA MI
49829-2019
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-1616
  • Fax: 906-428-2177
Mailing address:
  • Phone: 906-428-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE BOSK
Title or Position: OWNER
Credential: DMD
Phone: 906-428-1616