MEDICARE: BLONG INC.

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

General Provider Information

NPI Number	:	1588384861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLONG INC.

Provider Business Mailing Address
First Line	:	PO BOX 415
Second Line	:
City	:	WASHBURN
State	:	WI
Zip	:	54891-0415
Country	:	US
Telephone Number	:	715-373-2612
Fax Number	:	715-812-1114

Provider Business Practice Location Address
First Line	:	16 E BAYFIELD ST
Second Line	:
City	:	WASHBURN
State	:	WI
Zip	:	54891-4401
Country	:	US
Telephone Number	:	715-373-2612
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TERESA MATTHYS
Credential	:
Telephone Number	:	715-373-2612

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	08/29/2022

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Directions to “BLONG INC. ” Practice Location

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