MEDICARE: 97 SMILES OF GRAND RAPIDS

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	122300000X	Dentist

General Provider Information

NPI Number	:	1891654612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	97 SMILES OF GRAND RAPIDS

Provider Business Mailing Address
First Line	:	2300 3 MILE RD NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-3956
Country	:	US
Telephone Number	:	616-365-8699
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 3 MILE RD NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-3956
Country	:	US
Telephone Number	:	616-365-8699
Fax Number	:

Authorized Official
Title or Position	:	BILLING & CREDENTIALING MANAGER
Name	:	SUSAN DUNFORD
Credential	:
Telephone Number	:	313-342-1997

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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