Healthcare Provider Details

I. General information

NPI: 1417179466
Provider Name (Legal Business Name): DOCSMILE DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18601 MACK AVE
GROSSE POINTE MI
48236-3250
US

IV. Provider business mailing address

PO BOX 1082
DEARBORN MI
48121-1082
US

V. Phone/Fax

Practice location:
  • Phone: 800-362-7645
  • Fax:
Mailing address:
  • Phone: 800-362-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number2901015328
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number2901011576
License Number StateMI

VIII. Authorized Official

Name: MRS. TRACEY E JOHNSON-ROBINSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 800-362-7645