MEDICARE: SMILE ENVY 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

General Provider Information

NPI Number	:	1841982626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE ENVY PLLC

Provider Business Mailing Address
First Line	:	19 RIVERBANK DR
Second Line	:
City	:	BEVERLY HILLS
State	:	MI
Zip	:	48025-4802
Country	:	US
Telephone Number	:	586-354-3903
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	:	586-354-3903
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	ODETTE HAOUILOU
Credential	:
Telephone Number	:	586-354-3903

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	06/01/2023

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