Healthcare Provider Details

I. General information

NPI: 1538743323
Provider Name (Legal Business Name): IKRAM BLAOUI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2021
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2063 ALOMA AVE
WINTER PARK FL
32792-3319
US

IV. Provider business mailing address

1613 WATER ELM CT
ORLANDO FL
32825-5017
US

V. Phone/Fax

Practice location:
  • Phone: 407-673-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH28323
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: