Provider Demographics
NPI:1174524243
Name:SMITH, MICHAEL A (DDS, MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12662 RILEY ST
Mailing Address - Street 2:SUITE #130
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8023
Mailing Address - Country:US
Mailing Address - Phone:616-399-6811
Mailing Address - Fax:616-399-6812
Practice Address - Street 1:12662 RILEY ST
Practice Address - Street 2:SUITE #130
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8023
Practice Address - Country:US
Practice Address - Phone:616-399-6811
Practice Address - Fax:616-399-6812
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156301223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics