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General NPI Number Information
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NPI Number | 1265780704
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Entity Type | Organization
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Legal Business Name | BLANCO JAMIS DENTAL GROUP, P.A.
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Dates
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Enumeration Date | 08/15/2012
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Last Update Date | 11/17/2021
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Provider Practice Location Address
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Address Line | 5701 SW 107TH AVE STE 101
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City | MIAMI
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State | FL
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Zip | 33173-1276
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Country | US
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Telephone | 305-262-4604
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Fax | 305-239-8999
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Provider Business Mailing Address
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Address Line | PO BOX 440308
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City | MIAMI
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State | FL
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Zip | 33144-0308
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Country | US
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Telephone | 305-262-4604
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Fax | 305-239-8999
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JORGE L BLANCO
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Credential | DMD
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Telephone | 305-262-4604
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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 | DN 16115
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License Number State | FL
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