MEDICARE: NORTH SHORE DENTAL, LLC

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	5426-15	WI

General Provider Information

NPI Number	:	1932445442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE DENTAL, LLC

Provider Business Mailing Address
First Line	:	1345 W TOWNE SQUARE RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5047
Country	:	US
Telephone Number	:	262-242-1180
Fax Number	:	262-236-9079

Provider Business Practice Location Address
First Line	:	1345 W TOWNE SQUARE RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5047
Country	:	US
Telephone Number	:	262-242-1180
Fax Number	:	262-236-9079

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CRAIG L SMITH
Credential	:	DDS
Telephone Number	:	262-242-1180

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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