Healthcare Provider Details

I. General information

NPI: 1023118700
Provider Name (Legal Business Name): BLAYNE J GUMM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 INDIAN ROCKS RD N
BELLEAIR BLUFFS FL
33770-2085
US

IV. Provider business mailing address

490 INDIAN ROCKS RD N
BELLEAIR BLUFFS FL
33770-2085
US

V. Phone/Fax

Practice location:
  • Phone: 727-584-5693
  • Fax:
Mailing address:
  • Phone: 727-584-5693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7506
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: