Healthcare Provider Details

I. General information

NPI: 1073989497
Provider Name (Legal Business Name): BLAINE JOHNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 MCKAY RD
JACKSON MI
49201-9261
US

IV. Provider business mailing address

7040 MCKAY RD
JACKSON MI
49201-9261
US

V. Phone/Fax

Practice location:
  • Phone: 517-740-2596
  • Fax:
Mailing address:
  • Phone: 517-740-2596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902014285
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: