Provider Demographics
NPI:1659123040
Name:STATE STREET SMILES PLLC
Entity Type:Organization
Organization Name:STATE STREET SMILES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STEBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-322-5491
Mailing Address - Street 1:4709 CAMDEN DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7387
Mailing Address - Country:US
Mailing Address - Phone:616-322-5491
Mailing Address - Fax:
Practice Address - Street 1:300 S STATE ST STE 2
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1677
Practice Address - Country:US
Practice Address - Phone:616-322-5491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental