=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508332032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE NORTH MUSKEGON PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2018
-----------------------------------------------------
Last Update Date | 06/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1915 HOLTON RD STE C
-----------------------------------------------------
City | NORTH MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49445-1533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-719-0033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 COLUMBUS AVE
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-268-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OPERATIONS
-----------------------------------------------------
Name | LISA PAPES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-268-2092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------