=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558332056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ED BLANTON, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2006
-----------------------------------------------------
Last Update Date | 07/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2149 US HIGHWAY 441
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-728-6600
-----------------------------------------------------
Fax | 352-728-0585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2149 US HIGHWAY 441
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-728-6600
-----------------------------------------------------
Fax | 352-728-0585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ESMOND EDWARD BLANTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-728-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN0007820
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------