Healthcare Provider Details

I. General information

NPI: 1609046960
Provider Name (Legal Business Name): JORGE L BLANCO D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 CORAL WAY SUITE # 100
MIAMI FL
33155-6538
US

IV. Provider business mailing address

PO BOX 440308 SUITE # 100
MIAMI FL
33144-0308
US

V. Phone/Fax

Practice location:
  • Phone: 305-262-4604
  • Fax:
Mailing address:
  • Phone: 786-393-6875
  • Fax: 305-697-9785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: