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General NPI Number Information
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NPI Number | 1083624662
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Entity Type | Organization
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Legal Business Name | DOUGLAS A BLEYENBURG DDS PC
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 170 COLLEGE AVE #220
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City | HOLLAND
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State | MI
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Zip | 49423
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Country | US
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Telephone | 616-392-2302
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Fax | 616-392-9060
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Provider Business Mailing Address
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Address Line | 170 COLLEGE AVE #220
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City | HOLLAND
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State | MI
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Zip | 49423
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Country | US
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Telephone | 616-392-2302
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Fax | 616-392-9060
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DOUGLAS A BLEYENBURG
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Credential | DDS
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Telephone | 616-392-2302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 16773
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License Number State | MI
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