Healthcare Provider Details

I. General information

NPI: 1437892940
Provider Name (Legal Business Name): LIFETOUCH SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 N MACOMB ST
MONROE MI
48162-3197
US

IV. Provider business mailing address

1262 N MACOMB ST
MONROE MI
48162-3197
US

V. Phone/Fax

Practice location:
  • Phone: 734-241-6166
  • Fax:
Mailing address:
  • Phone: 734-241-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAWLAT HASSO
Title or Position: BUSINESS OWNER
Credential: DDS
Phone: 734-241-6166