Healthcare Provider Details

I. General information

NPI: 1861910101
Provider Name (Legal Business Name): JAMIE LEE BLUMHAGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 N 13TH ST
BISMARCK ND
58501-4283
US

IV. Provider business mailing address

600 E BOULEVARD AVE
BISMARCK ND
58505-0601
US

V. Phone/Fax

Practice location:
  • Phone: 701-527-8593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: