Provider Demographics
NPI:1184810376
Name:MICHAEL B BLUM DMD PA
Entity type:Organization
Organization Name:MICHAEL B BLUM DMD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-463-4999
Mailing Address - Street 1:648 NORTHEAST 3RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304
Mailing Address - Country:US
Mailing Address - Phone:954-463-4999
Mailing Address - Fax:954-463-6364
Practice Address - Street 1:648 NORTHEAST 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304
Practice Address - Country:US
Practice Address - Phone:954-463-4999
Practice Address - Fax:954-463-6364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00115671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty