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General NPI Number Information
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NPI Number | 1407396369
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Entity Type | Individual
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Provider Name | GONZALO BLASI DDS MS
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Gender | Male
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Dates
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Enumeration Date | 02/26/2017
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Last Update Date | 02/26/2017
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Provider Practice Location Address
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Address Line | 305 W FAYETTE ST APT 1412
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City | BALTIMORE
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State | MD
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Zip | 21201-3466
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Country | US
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Telephone | 443-980-8835
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Fax |
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Provider Business Mailing Address
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Address Line | 305 W FAYETTE ST APT 1412
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City | BALTIMORE
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State | MD
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Zip | 21201-3466
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Country | US
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Telephone | 443-980-8835
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 0401415436
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License Number State | VA
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