Provider Demographics
NPI:1689829913
Name:IRVING M BLAU DDS & RICHARD A KIRSCH DDS PC
Entity Type:Organization
Organization Name:IRVING M BLAU DDS & RICHARD A KIRSCH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVING
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-278-4470
Mailing Address - Street 1:24415 W WARREN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2223
Mailing Address - Country:US
Mailing Address - Phone:313-278-4470
Mailing Address - Fax:313-278-0124
Practice Address - Street 1:24415 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2223
Practice Address - Country:US
Practice Address - Phone:313-278-4470
Practice Address - Fax:313-278-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9971122300000X
MI12216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4049912Medicaid
MI4006263Medicaid