Basic Information
| Provider Information | |||||||||
| NPI: | 1003016791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | GARY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 184 NW CENTRAL PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728787348 | ||||||||
| FaxNumber: | 7728787534 | ||||||||
| Practice Location | |||||||||
| Address1: | 184 NW CENTRAL PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728787348 | ||||||||
| FaxNumber: | 7728787534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN9155 | FL | Y | Dental Providers | Dentist | General Practice |
No ID Information.