MEDICARE: DR. GARY ROBERT BLUMBERG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	17446	OH

General Provider Information

NPI Number	:	1548305188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ROBERT BLUMBERG DDS

Provider Business Mailing Address
First Line	:	293 N SOUTH ST
Second Line	:
City	:	WILMINGTON
State	:	OH
Zip	:	45177-1660
Country	:	US
Telephone Number	:	937-382-2042
Fax Number	:	937-382-8936

Provider Business Practice Location Address
First Line	:	293 N SOUTH ST
Second Line	:
City	:	WILMINGTON
State	:	OH
Zip	:	45177-1660
Country	:	US
Telephone Number	:	937-382-2042
Fax Number	:	937-382-8936

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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