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General NPI Number Information
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NPI Number | 1194946418
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Entity Type | Organization
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Legal Business Name | GREAT SMILE DENTISTRY
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2201 LUDINGTON ST
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City | ESCANABA
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State | MI
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Zip | 49829-2322
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Country | US
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Telephone | 906-786-4033
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Fax | 906-786-9199
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Provider Business Mailing Address
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Address Line | 2201 LUDINGTON ST
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City | ESCANABA
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State | MI
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Zip | 49829-2322
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Country | US
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Telephone | 906-786-4033
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Fax | 906-786-9199
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RANDY J BOGAUDO
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Credential |
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Telephone | 906-786-4033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 15587
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License Number State | MI
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