Provider Demographics
NPI:1003008723
Name:BLAND, TEDDY ROGER JR (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:ROGER
Last Name:BLAND
Suffix:JR
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 E ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4343
Mailing Address - Country:US
Mailing Address - Phone:352-735-2005
Mailing Address - Fax:
Practice Address - Street 1:1340 E ORANGE AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4343
Practice Address - Country:US
Practice Address - Phone:352-735-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 17164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist