Healthcare Provider Details

I. General information

NPI: 1063347771
Provider Name (Legal Business Name): BRIANNA BLETCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28282 DEQUINDRE RD
WARREN MI
48092-5604
US

IV. Provider business mailing address

11611 ROBINWOOD BLVD
WARREN MI
48093-3067
US

V. Phone/Fax

Practice location:
  • Phone: 586-574-2620
  • Fax:
Mailing address:
  • Phone: 586-350-7044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901603170
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: