Provider Demographics
NPI:1811140973
Name:BLEYENBURG, DOUGLAS A (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:BLEYENBURG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 COLLEGE AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-2982
Mailing Address - Country:US
Mailing Address - Phone:616-392-2302
Mailing Address - Fax:616-392-9070
Practice Address - Street 1:170 COLLEGE AVE STE 220
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2982
Practice Address - Country:US
Practice Address - Phone:616-392-2302
Practice Address - Fax:616-392-9070
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist