Provider Demographics
NPI:1124013982
Name:BLOOD, JAMES EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:BLOOD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 KNOB CREEK LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6618
Mailing Address - Country:US
Mailing Address - Phone:618-632-1971
Mailing Address - Fax:
Practice Address - Street 1:375 DENTAL SQUADRON
Practice Address - Street 2:310 W. LOSEY ST.
Practice Address - City:DENTAL SQUADRON
Practice Address - State:IN
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-256-2750
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-209401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN