Provider Demographics
NPI:1063920932
Name:NICE SMILE DENTISTRY PC
Entity type:Organization
Organization Name:NICE SMILE DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:GEORGES
Authorized Official - Last Name:CHABIAAA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-624-5533
Mailing Address - Street 1:1052 E WEST MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3571
Mailing Address - Country:US
Mailing Address - Phone:313-269-4564
Mailing Address - Fax:
Practice Address - Street 1:1052 E WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3571
Practice Address - Country:US
Practice Address - Phone:248-624-5533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-13
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017752122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922173806Medicaid