Healthcare Provider Details

I. General information

NPI: 1396276333
Provider Name (Legal Business Name): DENTISTRY BY DESIGN OF JACKSON, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W WASHINGTON AVE STE 205
JACKSON MI
49201-2141
US

IV. Provider business mailing address

306 W WASHINGTON AVE STE 205
JACKSON MI
49201-2141
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-5055
  • Fax: 517-787-9346
Mailing address:
  • Phone: 517-787-5055
  • Fax: 517-787-9346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901020967
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW JAMES BALAZE
Title or Position: DENTIST/OWNER
Credential: D.M.D.
Phone: 517-787-5055