Healthcare Provider Details

I. General information

NPI: 1710463542
Provider Name (Legal Business Name): BLAKE BUFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

IV. Provider business mailing address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-3326
  • Fax:
Mailing address:
  • Phone: 734-763-3326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022653
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: