Provider Demographics
NPI:1598253015
Name:GREAT SMILE DENTAL GROUP PC
Entity Type:Organization
Organization Name:GREAT SMILE DENTAL GROUP PC
Other - Org Name:HARRIS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROUZANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-871-2222
Mailing Address - Street 1:8721 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3720
Mailing Address - Country:US
Mailing Address - Phone:313-871-2222
Mailing Address - Fax:
Practice Address - Street 1:8721 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3720
Practice Address - Country:US
Practice Address - Phone:313-871-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty