Healthcare Provider Details

I. General information

NPI: 1902334006
Provider Name (Legal Business Name): MAUREEN MIKHO BLACKBURN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W PATERSON ST
KALAMAZOO MI
49007-2581
US

IV. Provider business mailing address

117 W PATERSON ST
KALAMAZOO MI
49007-2557
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-2641
  • Fax:
Mailing address:
  • Phone: 269-349-2641
  • Fax: 269-201-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022231
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: