Provider Demographics
NPI:1407010010
Name:BLANCHARD, SAMUEL GREGG (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GREGG
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:BLANCHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:SUITE 1180
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2184
Mailing Address - Country:US
Mailing Address - Phone:248-668-0022
Mailing Address - Fax:
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE 1180
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-668-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-13
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019904122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist