Provider Demographics
NPI:1225287790
Name:PAUL M BLANK D.D.S., P.C.
Entity Type:Organization
Organization Name:PAUL M BLANK D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-279-5278
Mailing Address - Street 1:213 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-2150
Mailing Address - Country:US
Mailing Address - Phone:269-279-5278
Mailing Address - Fax:269-278-1014
Practice Address - Street 1:213 SPRING ST
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-2150
Practice Address - Country:US
Practice Address - Phone:269-279-5278
Practice Address - Fax:269-278-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015109385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2826055Medicaid