Healthcare Provider Details

I. General information

NPI: 1003976994
Provider Name (Legal Business Name): MICHAEL P BLUM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W LA PALMA AVE SUITE 604
ANAHEIM CA
92801-2815
US

IV. Provider business mailing address

1211 W LA PALMA AVE SUITE 604
ANAHEIM CA
92801-2815
US

V. Phone/Fax

Practice location:
  • Phone: 714-772-2200
  • Fax: 714-520-0969
Mailing address:
  • Phone: 714-772-2200
  • Fax: 714-520-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD25236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: