Healthcare Provider Details

I. General information

NPI: 1407152705
Provider Name (Legal Business Name): JOHN P BLAZIC DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NILLES ROAD SUITE 12
FAIRFIELD OH
45014-7205
US

IV. Provider business mailing address

1251 NILLES ROAD SUITE 12
FAIRFIELD OH
45014-7205
US

V. Phone/Fax

Practice location:
  • Phone: 513-829-4111
  • Fax: 513-829-5140
Mailing address:
  • Phone: 513-829-4111
  • Fax: 513-829-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30017039
License Number StateOH

VIII. Authorized Official

Name: DR. JOHN P BLAZIC
Title or Position: OWNER
Credential: DDS
Phone: 513-829-4111