Provider Demographics
NPI:1083624662
Name:DOUGLAS A BLEYENBURG DDS PC
Entity Type:Organization
Organization Name:DOUGLAS A BLEYENBURG DDS PC
Other - Org Name:DENTAL OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLEYENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-392-2302
Mailing Address - Street 1:170 COLLEGE AVE
Mailing Address - Street 2:#220
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423
Mailing Address - Country:US
Mailing Address - Phone:616-392-2302
Mailing Address - Fax:616-392-9060
Practice Address - Street 1:170 COLLEGE AVE
Practice Address - Street 2:#220
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-392-2302
Practice Address - Fax:616-392-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty