Healthcare Provider Details

I. General information

NPI: 1467105403
Provider Name (Legal Business Name): BALRAJ BAINS DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4790 CASCADE RD SE
GRAND RAPIDS MI
49546-8424
US

IV. Provider business mailing address

3434 FULTON ST E
GRAND RAPIDS MI
49546-1317
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-3977
  • Fax:
Mailing address:
  • Phone: 205-563-4342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901601192
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: