Healthcare Provider Details

I. General information

NPI: 1548027063
Provider Name (Legal Business Name): JACKSON DENTAL INNOVATIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 HORTON RD STE 14
JACKSON MI
49203-5599
US

IV. Provider business mailing address

190 PLYMOUTH RD
PLYMOUTH MI
48170-1447
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-7520
  • Fax: 517-787-2575
Mailing address:
  • Phone: 734-979-0979
  • Fax: 734-927-1169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHADI KRECHT
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 734-979-0979