MEDICARE: BAKER COLLEGE OF PORT HURON

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	015451	MI

General Provider Information

NPI Number	:	1962523001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAKER COLLEGE OF PORT HURON

Provider Business Mailing Address
First Line	:	3403 LAPEER ROAD
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-2597
Country	:	US
Telephone Number	:	810-985-3729
Fax Number	:	810-985-7066

Provider Business Practice Location Address
First Line	:	3403 LAPEER ROAD
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-2597
Country	:	US
Telephone Number	:	810-985-3729
Fax Number	:	810-985-7066

Authorized Official
Title or Position	:	SUPERVISING DENTIST
Name	:	DR. DAVID P SMITH
Credential	:	DDS
Telephone Number	:	810-985-3729

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/22/2020

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