Healthcare Provider Details

I. General information

NPI: 1851677850
Provider Name (Legal Business Name): BRYAN BLAZER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVE 633D MEDICAL GROUP
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

IV. Provider business mailing address

77 NEALY AVE 633D MEDICAL GROUP
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 764-225-5039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.028688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: