Healthcare Provider Details

I. General information

NPI: 1124172424
Provider Name (Legal Business Name): WILLIAM BLANK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W PATERSON ST
KALAMAZOO MI
49007-2557
US

IV. Provider business mailing address

1705 CHICORY RDG
ANN ARBOR MI
48103-8838
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-2641
  • Fax: 269-488-8101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901017512
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: