=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124154539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL SMILES OF LIVONIA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 02/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | OTSEGO DENTAL GROUP 785 M-32
-----------------------------------------------------
City | GAYLORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48735-4873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-448-2664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2385 WOODVALE TRL
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48114-8149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-634-4077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. KRISTAL GRENIUK-WIONCEK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 734-634-4077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------