Provider Demographics
NPI:1891892006
Name:DENTAL DESIGN P.C.
Entity type:Organization
Organization Name:DENTAL DESIGN P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-452-0400
Mailing Address - Street 1:PO BOX 88007
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49518-0007
Mailing Address - Country:US
Mailing Address - Phone:616-452-0400
Mailing Address - Fax:855-918-1014
Practice Address - Street 1:2021 44TH ST SE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5349
Practice Address - Country:US
Practice Address - Phone:616-452-0400
Practice Address - Fax:855-918-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2759918Medicaid