MEDICARE: DR. DAVID JENNINGS BLONG D.D.S.

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	5709-015	WI

General Provider Information

NPI Number	:	1639190143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID JENNINGS BLONG D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 415
Second Line	:
City	:	WASHBURN
State	:	WI
Zip	:	54891-0415
Country	:	US
Telephone Number	:	715-373-2612
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 E BAYFIELD ST
Second Line	:
City	:	WASHBURN
State	:	WI
Zip	:	54891-4401
Country	:	US
Telephone Number	:	715-373-2612
Fax Number	:

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	03/27/2019

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