1548027063 NPI number — JACKSON DENTAL INNOVATIONS PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548027063 NPI number — JACKSON DENTAL INNOVATIONS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON DENTAL INNOVATIONS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548027063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 PLYMOUTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48170-1447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-979-0979
Provider Business Mailing Address Fax Number:
734-927-1169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1931 HORTON RD STE 14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49203-5599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-787-7520
Provider Business Practice Location Address Fax Number:
517-787-2575
Provider Enumeration Date:
03/01/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KRECHT
Authorized Official First Name:
SHADI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
734-979-0979

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)