Provider Demographics
NPI:1194124339
Name:THOMAS J AND EFFIE K BLUE, DMD, PA
Entity type:Organization
Organization Name:THOMAS J AND EFFIE K BLUE, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-768-0991
Mailing Address - Street 1:575 S WICKHAM RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1170
Mailing Address - Country:US
Mailing Address - Phone:321-768-0991
Mailing Address - Fax:321-727-7909
Practice Address - Street 1:575 S WICKHAM RD
Practice Address - Street 2:SUITE D
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1170
Practice Address - Country:US
Practice Address - Phone:321-768-0991
Practice Address - Fax:321-727-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN95541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty