Healthcare Provider Details

I. General information

NPI: 1518956978
Provider Name (Legal Business Name): TRINA MARIE BLUNT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 S LUELLA AVE
CHICAGO IL
60617-1152
US

IV. Provider business mailing address

8100 S LUELLA AVE
CHICAGO IL
60617-1152
US

V. Phone/Fax

Practice location:
  • Phone: 217-202-5634
  • Fax: 217-351-5104
Mailing address:
  • Phone: 217-202-5634
  • Fax: 217-351-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: