MEDICARE: ONE GOOD SMILE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service
2	305S00000X	Point of Service	30022586	OH

General Provider Information

NPI Number	:	1366929820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE GOOD SMILE

Provider Business Mailing Address
First Line	:	802 GRAHAM RD
Second Line	:
City	:	CUYAHOGA FALLS
State	:	OH
Zip	:	44221-1049
Country	:	US
Telephone Number	:	330-929-7344
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 GRAHAM ROAD
Second Line	:
City	:	CUYAHOGA FALLS
State	:	OH
Zip	:	44221-1049
Country	:	US
Telephone Number	:	330-929-7344
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. BRENT A VAN HALA
Credential	:	DDS
Telephone Number	:	330-929-7344

Provider Enumeration Date	:	07/26/2018
Last Update Date	:	07/26/2018

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Directions to “ONE GOOD SMILE ” Practice Location

Language	Start Address	Practice Location

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