Provider Demographics
NPI:1417179466
Name:DOCSMILE DENTAL CENTER
Entity type:Organization
Organization Name:DOCSMILE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON-ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-362-7645
Mailing Address - Street 1:PO BOX 1082
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121-1082
Mailing Address - Country:US
Mailing Address - Phone:800-362-7645
Mailing Address - Fax:
Practice Address - Street 1:18601 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236-3250
Practice Address - Country:US
Practice Address - Phone:800-362-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015328292200000X
MI2901011576292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2737563Medicaid
MI4490053Medicaid