Provider Demographics
NPI:1003016791
Name:BLANK, STEPHEN GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GARY
Last Name:BLANK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 NW CENTRAL PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2451
Mailing Address - Country:US
Mailing Address - Phone:772-878-7348
Mailing Address - Fax:772-878-7534
Practice Address - Street 1:184 NW CENTRAL PARK PLZ
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2451
Practice Address - Country:US
Practice Address - Phone:772-878-7348
Practice Address - Fax:772-878-7534
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN91551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice