MEDICARE: SMILES OF GRAND RIVER PLLC

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	1223G0001X	General Practice Dentistry	2901021018	MI

General Provider Information

NPI Number	:	1710341102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES OF GRAND RIVER PLLC

Provider Business Mailing Address
First Line	:	55840 GRAND RIVER AVE
Second Line	:	SUITE 350
City	:	NEW HUDSON
State	:	MI
Zip	:	48165-9717
Country	:	US
Telephone Number	:	734-707-8764
Fax Number	:

Provider Business Practice Location Address
First Line	:	55840 GRAND RIVER AVE
Second Line	:	SUITE 350
City	:	NEW HUDSON
State	:	MI
Zip	:	48165-9717
Country	:	US
Telephone Number	:	734-707-8764
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES SHAHEEN
Credential	:	D.D.S.
Telephone Number	:	248-561-0316

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	04/12/2016

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