Provider Demographics
NPI:1255824371
Name:CALLEJA BLANCO, SERGIO FABIAN (DDS)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:FABIAN
Last Name:CALLEJA BLANCO
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8524
Mailing Address - Country:US
Mailing Address - Phone:734-353-1251
Mailing Address - Fax:517-337-9759
Practice Address - Street 1:7611 LITTLE RIVER TPKE STE 101E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2630
Practice Address - Country:US
Practice Address - Phone:703-634-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022647122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist