Provider Demographics
NPI:1316767163
Name:BRIDGE STREET SMILES, PLLC
Entity type:Organization
Organization Name:BRIDGE STREET SMILES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:LYN-IREY
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-526-1234
Mailing Address - Street 1:9645 TOWNER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-9481
Mailing Address - Country:US
Mailing Address - Phone:517-526-1234
Mailing Address - Fax:
Practice Address - Street 1:119 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1434
Practice Address - Country:US
Practice Address - Phone:517-647-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty