Basic Information
| Provider Information | |||||||||
| NPI: | 1245363498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HU | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346474166 | ||||||||
| FaxNumber: | 7346157294 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346474166 | ||||||||
| FaxNumber: | 7346157294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901017619 | MI | N | Dental Providers | Dentist | 1223P0221X | 2901017619 | MI | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 2667565 | 05 | OH | MEDICAID | D176190 | 01 | MI | BCBS OF MI DENTAL | OTHER | 4747308 | 05 | MI | MEDICAID | 4747317 | 05 | MI | MEDICAID | 1958111960 | 01 | MI | BCBS OF MI MED SURGICAL | OTHER |