Provider Demographics
NPI:1639373285
Name:SMILANICH, MICHAEL D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:SMILANICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11231 AQUILA DR N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316
Mailing Address - Country:US
Mailing Address - Phone:763-275-1318
Mailing Address - Fax:763-400-9184
Practice Address - Street 1:11231 AQUILA DR N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316
Practice Address - Country:US
Practice Address - Phone:763-275-1318
Practice Address - Fax:763-400-9184
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9510122300000X
WI3281WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice