Provider Demographics
NPI:1952058133
Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF JACKSON
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LY
Authorized Official - Middle Name:JULIE
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-744-9869
Mailing Address - Street 1:900 E MICHIGAN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2457
Mailing Address - Country:US
Mailing Address - Phone:517-376-3142
Mailing Address - Fax:
Practice Address - Street 1:900 E MICHIGAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2457
Practice Address - Country:US
Practice Address - Phone:517-376-3142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty