Provider Demographics
NPI:1073989497
Name:JOHNS, BLAINE
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:JOHNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 MCKAY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9261
Mailing Address - Country:US
Mailing Address - Phone:517-740-2596
Mailing Address - Fax:
Practice Address - Street 1:7040 MCKAY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9261
Practice Address - Country:US
Practice Address - Phone:517-740-2596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014285124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist