Provider Demographics
NPI:1851730592
Name:BALAZE, ANDREW JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAMES
Last Name:BALAZE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W WASHINGTON AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2141
Mailing Address - Country:US
Mailing Address - Phone:517-787-5055
Mailing Address - Fax:
Practice Address - Street 1:306 W WASHINGTON AVE STE 205
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2141
Practice Address - Country:US
Practice Address - Phone:517-787-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-16
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020967332B00000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies