Basic Information
| Provider Information | |||||||||
| NPI: | 1699256792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHEN G. BLANK, DDS, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STEPHEN G. BLANK, DDS, PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 NW CENTRAL PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728787348 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 184 NW CENTRAL PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728787348 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2018 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLANK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7728787348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | DN9155 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.