Provider Demographics
NPI:1992414981
Name:SMILE AVENUE FAMILY AND COSMETIC DENTISTRY
Entity type:Organization
Organization Name:SMILE AVENUE FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSKUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-878-1595
Mailing Address - Street 1:519 W CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1892
Mailing Address - Country:US
Mailing Address - Phone:517-279-7900
Mailing Address - Fax:
Practice Address - Street 1:519 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1892
Practice Address - Country:US
Practice Address - Phone:517-279-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty