1265780704 NPI number — BLANCO JAMIS DENTAL GROUP, P.A.

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 1265780704 NPI number — BLANCO JAMIS DENTAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLANCO JAMIS DENTAL GROUP, P.A.
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:
1265780704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 440308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33144-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-262-4604
Provider Business Mailing Address Fax Number:
305-239-8999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 SW 107TH AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33173-1276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-262-4604
Provider Business Practice Location Address Fax Number:
305-239-8999
Provider Enumeration Date:
08/15/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLANCO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-262-4604

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN 16115 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1609046960 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".