Provider Demographics
NPI:1124134283
Name:BLAHA, PAUL J (DDS MS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:BLAHA
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1976 ABERDEEN COURT
Mailing Address - Street 2:SUITE A
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-758-3457
Mailing Address - Fax:815-758-0274
Practice Address - Street 1:1976 ABERDEEN COURT
Practice Address - Street 2:SUITE A
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-758-3457
Practice Address - Fax:815-758-0274
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics