Provider Demographics
NPI:1154996700
Name:BLAZEJEWSKI, JUSTIN EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:EDWARD
Last Name:BLAZEJEWSKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 S RANCHO DR STE 205
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-4456
Mailing Address - Country:US
Mailing Address - Phone:702-779-3668
Mailing Address - Fax:
Practice Address - Street 1:1860 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1949
Practice Address - Country:US
Practice Address - Phone:702-779-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program