=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073888798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LELAND S BLOUGH JR DMD LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2012
-----------------------------------------------------
Last Update Date | 03/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 COLLEGE HILL RD SUITE 5A
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-828-3688
-----------------------------------------------------
Fax | 401-828-8588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 COLLEGE HILL RD SUITE 5A
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-828-3688
-----------------------------------------------------
Fax | 401-828-8588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LELAND S BLOUGH JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 401-828-3688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2455
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------