Healthcare Provider Details

I. General information

NPI: 1891892006
Provider Name (Legal Business Name): DENTAL DESIGN P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 44TH ST SE STE B
GRAND RAPIDS MI
49508-5349
US

IV. Provider business mailing address

PO BOX 88007
GRAND RAPIDS MI
49518-0007
US

V. Phone/Fax

Practice location:
  • Phone: 616-452-0400
  • Fax: 855-918-1014
Mailing address:
  • Phone: 616-452-0400
  • Fax: 855-918-1014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901015828
License Number StateMI

VIII. Authorized Official

Name: DR. TRACY ELAINE BLOUNT
Title or Position: PRESIDENT
Credential: DDS
Phone: 616-452-0400