MEDICARE: EPIC SMILE CENTERS OF MICHIGAN 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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1770628687	OTHER	MI	DENTIST

General Provider Information

NPI Number	:	1730647272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EPIC SMILE CENTERS OF MICHIGAN PLLC

Provider Business Mailing Address
First Line	:	17968 FIELDBROOK CIR S
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33496-1531
Country	:	US
Telephone Number	:	561-866-3040
Fax Number	:

Provider Business Practice Location Address
First Line	:	30969 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-1338
Country	:	US
Telephone Number	:	866-374-2764
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. JARED WOOLF
Credential	:	DDS
Telephone Number	:	561-866-3040

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	03/03/2021

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