Healthcare Provider Details

I. General information

NPI: 1639598147
Provider Name (Legal Business Name): ANDREA BLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 NEW JERSEY AVE
WILDWOOD NJ
08260-6154
US

IV. Provider business mailing address

101 SEACREST LN
RIO GRANDE NJ
08242-2837
US

V. Phone/Fax

Practice location:
  • Phone: 609-465-0258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number22H100629100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: