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General NPI Number Information
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NPI Number | 1598187247
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Entity Type | Organization
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Legal Business Name | SWEET SMILES GRAFTON LLC
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Dates
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Enumeration Date | 01/15/2014
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Last Update Date | 10/01/2020
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Provider Practice Location Address
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Address Line | 1300 BRIDGE ST
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City | GRAFTON
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State | WI
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Zip | 53024-1948
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Country | US
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Telephone | 262-377-0807
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 BRIDGE ST
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City | GRAFTON
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State | WI
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Zip | 53024-1948
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Country | US
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Telephone | 262-377-0807
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | PAVAN GORANTLA
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Credential |
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Telephone | 262-377-0807
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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 |
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License Number State |
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