Healthcare Provider Details

I. General information

NPI: 1316217649
Provider Name (Legal Business Name): N BRUCE BLAUM DMD MAGD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8076 SPRING RUN DR
FAIRHOPE AL
36532-3854
US

IV. Provider business mailing address

PO BOX 1027
MONTROSE AL
36559-1027
US

V. Phone/Fax

Practice location:
  • Phone: 251-232-1083
  • Fax: 866-291-0167
Mailing address:
  • Phone: 251-232-1083
  • Fax: 866-291-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4072
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. NORMAN B BLAUM
Title or Position: MEMBER
Credential: DMD
Phone: 251-232-1083