Healthcare Provider Details

I. General information

NPI: 1306691381
Provider Name (Legal Business Name): JACKSON IMPLANTS & PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 17TH STREET
JACKSON MI
49203
US

IV. Provider business mailing address

721 17TH STREET
JACKSON MI
49203
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-3607
  • Fax: 517-782-3658
Mailing address:
  • Phone: 517-782-3607
  • Fax: 517-782-3658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: KELLY MISCH
Title or Position: OWNER/PERIODONTIST
Credential: DDS, MS
Phone: 734-975-1743