Provider Demographics
NPI:1073888798
Name:LELAND S BLOUGH JR DMD LTD
Entity Type:Organization
Organization Name:LELAND S BLOUGH JR DMD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLOUGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-828-3688
Mailing Address - Street 1:33 COLLEGE HILL RD
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2776
Mailing Address - Country:US
Mailing Address - Phone:401-828-3688
Mailing Address - Fax:401-828-8588
Practice Address - Street 1:33 COLLEGE HILL RD
Practice Address - Street 2:SUITE 5A
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2776
Practice Address - Country:US
Practice Address - Phone:401-828-3688
Practice Address - Fax:401-828-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI24551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI198008128OtherPTAN
RI198008128OtherPTAN