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General NPI Number Information
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NPI Number | 1194124339
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Entity Type | Organization
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Legal Business Name | THOMAS J AND EFFIE K BLUE, DMD, PA
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Dates
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Enumeration Date | 08/13/2014
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Last Update Date | 08/13/2014
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Provider Practice Location Address
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Address Line | 575 S WICKHAM RD SUITE D
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City | W MELBOURNE
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State | FL
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Zip | 32904-1170
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Country | US
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Telephone | 321-768-0991
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Fax | 321-727-7909
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Provider Business Mailing Address
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Address Line | 575 S WICKHAM RD SUITE D
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City | W MELBOURNE
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State | FL
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Zip | 32904-1170
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Country | US
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Telephone | 321-768-0991
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Fax | 321-727-7909
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. THOMAS J BLUE
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Credential | D.M.D.
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Telephone | 321-768-0991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN9554
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License Number State | FL
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