=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851100168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE DETROIT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2025
-----------------------------------------------------
Last Update Date | 01/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 W 11 MILE RD
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48067-2447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-485-7369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 W 11 MILE RD
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48067-2447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | ANTHONIO COLLINS MCFADDEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 313-485-7369
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------