Provider Demographics
NPI:1396276333
Name:DENTISTRY BY DESIGN OF JACKSON, PLC
Entity type:Organization
Organization Name:DENTISTRY BY DESIGN OF JACKSON, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BALAZE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:517-787-5055
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:517-787-9346
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:517-787-9346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTISTRY BY DESIGN OF JACKSON, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-22
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI2901020967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty