MEDICARE: DR. STACEY PLATT BLAU DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	34606	NY

General Provider Information

NPI Number	:	1528288388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY PLATT BLAU DDS

Provider Business Mailing Address
First Line	:	4960 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-2314
Country	:	US
Telephone Number	:	212-567-1592
Fax Number	:	212-567-3855

Provider Business Practice Location Address
First Line	:	4960 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-2314
Country	:	US
Telephone Number	:	212-567-1592
Fax Number	:	212-567-3855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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