Provider Demographics
NPI:1164868808
Name:BEZZO, JEREMY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:M
Last Name:BEZZO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-5903
Mailing Address - Country:US
Mailing Address - Phone:734-281-2710
Mailing Address - Fax:
Practice Address - Street 1:45 ELM ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-5903
Practice Address - Country:US
Practice Address - Phone:734-281-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010209021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice