Healthcare Provider Details

I. General information

NPI: 1467737684
Provider Name (Legal Business Name): BLUM-NICO ORAL FACIAL SURGERY ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 ALTON RD STE 850
MIAMI BEACH FL
33140-4558
US

IV. Provider business mailing address

4308 ALTON RD STE 850
MIAMI BEACH FL
33140-4558
US

V. Phone/Fax

Practice location:
  • Phone: 305-538-4556
  • Fax: 305-538-2019
Mailing address:
  • Phone: 305-538-4556
  • Fax: 305-538-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberL11000065863
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberL11000065863
License Number StateFL

VIII. Authorized Official

Name: DR. JEFFERY D. BLUM
Title or Position: OWNER
Credential: DENTIST
Phone: 305-538-4556