Healthcare Provider Details

I. General information

NPI: 1689444622
Provider Name (Legal Business Name): VILLAGE FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/02/2024
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1671 WEST US HWY 12 SUITE B
CLINTON MI
49236
US

IV. Provider business mailing address

1671 WEST US HWY 12 SUITE B
CLINTON MI
49236
US

V. Phone/Fax

Practice location:
  • Phone: 517-456-9972
  • Fax: 517-456-9973
Mailing address:
  • Phone: 517-456-9972
  • Fax: 517-456-9973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HELIN JACKSI
Title or Position: OWNER
Credential: DDS
Phone: 734-489-3974