Healthcare Provider Details

I. General information

NPI: 1720008329
Provider Name (Legal Business Name): JOHN F BLATTNER D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 WESTVIEW PLAZA DR.
WATERLOO IL
62298-1253
US

IV. Provider business mailing address

226 WESTVIEW PLAZA DR.
WATERLOO IL
62298-1253
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4042
  • Fax: 618-939-5404
Mailing address:
  • Phone: 618-939-4042
  • Fax: 618-939-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number019016532
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number019016532
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19-016532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: