Provider Demographics
NPI:1699256792
Name:STEPHEN G. BLANK, DDS, PA
Entity type:Organization
Organization Name:STEPHEN G. BLANK, DDS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:772-878-7348
Mailing Address - Street 1:184 NW CENTRAL PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2451
Mailing Address - Country:US
Mailing Address - Phone:772-878-7348
Mailing Address - Fax:
Practice Address - Street 1:184 NW CENTRAL PARK PLZ
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2451
Practice Address - Country:US
Practice Address - Phone:772-878-7348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9155261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental