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General NPI Number Information
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NPI Number | 1902397862
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Entity Type | Individual
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Provider Name | JENNIFER LYNN DEBLOUW DDS
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Gender | Female
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Dates
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Enumeration Date | 05/25/2018
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Last Update Date | 06/26/2020
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Provider Practice Location Address
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Address Line | 1980 FRED W MOORE HWY
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City | SAINT CLAIR
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State | MI
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Zip | 48079-4701
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Country | US
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Telephone | 810-329-7440
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Fax |
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Provider Business Mailing Address
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Address Line | 26551 24 MILE RD
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City | CHESTERFIELD
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State | MI
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Zip | 48051-1515
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Country | US
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Telephone | 810-531-0142
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22632
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901022632
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License Number State | MI
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