Healthcare Provider Details

I. General information

NPI: 1679062772
Provider Name (Legal Business Name): SMILE CASCADE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 CASCADE RD SE # A
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

128 COLUMBUS AVE
GRAND HAVEN MI
49417-1224
US

V. Phone/Fax

Practice location:
  • Phone: 616-228-1210
  • Fax:
Mailing address:
  • Phone: 616-850-3970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number16820
License Number StateMI

VIII. Authorized Official

Name: DARREN M RIOPELLE
Title or Position: CEO
Credential:
Phone: 616-268-2090