Healthcare Provider Details

I. General information

NPI: 1952058133
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY AND ORTHODONTICS OF JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E MICHIGAN AVE STE 100
JACKSON MI
49201-2457
US

IV. Provider business mailing address

900 E MICHIGAN AVE STE 100
JACKSON MI
49201-2457
US

V. Phone/Fax

Practice location:
  • Phone: 517-376-3142
  • Fax:
Mailing address:
  • Phone: 517-376-3142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LY JULIE VAN
Title or Position: PEDIATRIC DENTIST
Credential: DDS
Phone: 586-744-9869