Healthcare Provider Details

I. General information

NPI: 1922677335
Provider Name (Legal Business Name): SMILE ITHACA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN ST
ITHACA MI
48847-1440
US

IV. Provider business mailing address

128 COLUMBUS AVE
GRAND HAVEN MI
49417-1224
US

V. Phone/Fax

Practice location:
  • Phone: 989-875-4832
  • Fax:
Mailing address:
  • Phone: 616-268-2090
  • 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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DARREN RIOPELLE
Title or Position: OWNER, CEO
Credential: DDS
Phone: 616-502-8023