MEDICARE: DR. MARC BLUMENTHAL 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	122300000X	Dentist	041623	NY

General Provider Information

NPI Number	:	1578898623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARC BLUMENTHAL DDS

Provider Business Mailing Address
First Line	:	22024 HILLSIDE AVE
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11427-2020
Country	:	US
Telephone Number	:	718-479-7100
Fax Number	:	718-479-1556

Provider Business Practice Location Address
First Line	:	22024 HILLSIDE AVE
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11427-2020
Country	:	US
Telephone Number	:	718-479-7100
Fax Number	:	718-479-1556

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

Provider Enumeration Date	:	10/07/2009
Last Update Date	:	10/07/2009

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