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General NPI Number Information
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NPI Number | 1114006434
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Entity Type | Organization
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Legal Business Name | JUPITER PROSTHODONTICS
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 200 CENTRAL BLVD STE A
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City | JUPITER
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State | FL
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Zip | 33458
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Country | US
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Telephone | 561-745-5550
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Fax | 561-745-8442
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Provider Business Mailing Address
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Address Line | 200 CENTRAL BLVD STE A
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City | JUPITER
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State | FL
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Zip | 33458
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Country | US
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Telephone | 561-745-5550
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Fax | 561-745-8442
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Authorized Official
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Title or Position | OWNER MANAGER
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Name | DR. ROY C BLAKE III
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Credential | DDS MSD
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Telephone | 561-745-5550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | DN16512
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | DN9551
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License Number State | FL
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