1518330992 NPI number — SMILES ON WHEELS

Table of content: (NPI 1518330992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518330992 NPI number — SMILES ON WHEELS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILES ON WHEELS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518330992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 HIGHLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49201-9164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1715 LANSING AVE
Provider Second Line Business Practice Location Address:
ROOM 261
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49202-2192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-740-7422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRABTREE
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTAL HYGIENIST/OWNER
Authorized Official Telephone Number:
517-740-2596

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  2902016316 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)