Healthcare Provider Details

I. General information

NPI: 1104743624
Provider Name (Legal Business Name): 97 SMILES OF JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 N WISNER ST
JACKSON MI
49202-3141
US

IV. Provider business mailing address

826 N WISNER ST
JACKSON MI
49202-3141
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-0401
  • Fax:
Mailing address:
  • Phone: 517-787-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN DUNFORD
Title or Position: BILLING & CREDENTIALING MANAGER
Credential:
Phone: 734-788-8712