Healthcare Provider Details

I. General information

NPI: 1720102882
Provider Name (Legal Business Name): WILLIAM JOHN BLUM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 24TH AVE SW
NORMAN OK
73069-3946
US

IV. Provider business mailing address

700 24TH AVE SW
NORMAN OK
73069-3946
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5566
  • Fax: 405-360-2746
Mailing address:
  • Phone: 405-360-5566
  • Fax: 405-360-2746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4455
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4455
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: