Provider Demographics
NPI:1164963401
Name:SMILE FRESH DETROIT PC
Entity Type:Organization
Organization Name:SMILE FRESH DETROIT PC
Other - Org Name:SMILE FRESH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAUZI
Authorized Official - Middle Name:MOHAMMED
Authorized Official - Last Name:RAZIUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-895-6987
Mailing Address - Street 1:1507 THREADNEEDLE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1020
Mailing Address - Country:US
Mailing Address - Phone:248-895-6987
Mailing Address - Fax:
Practice Address - Street 1:7230 GRATIOT AVENUE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213
Practice Address - Country:US
Practice Address - Phone:248-895-6987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010217271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty