Provider Demographics
NPI:1275766461
Name:JASON C. DOUBLESTEIN, D.D.S., P.L.L.C.
Entity Type:Organization
Organization Name:JASON C. DOUBLESTEIN, D.D.S., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:DOUBLESTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PLLC
Authorized Official - Phone:616-530-2200
Mailing Address - Street 1:4320 44TH ST SW
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2300
Mailing Address - Country:US
Mailing Address - Phone:616-530-2200
Mailing Address - Fax:616-530-8250
Practice Address - Street 1:4320 44TH ST SW
Practice Address - Street 2:SUITE 106
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2300
Practice Address - Country:US
Practice Address - Phone:616-530-2200
Practice Address - Fax:616-530-8250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010188061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386760072OtherDENTIST
MI1952426371OtherDENTIST