Provider Demographics
NPI:1316217649
Name:N BRUCE BLAUM DMD MAGD LLC
Entity Type:Organization
Organization Name:N BRUCE BLAUM DMD MAGD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-232-1083
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:AL
Mailing Address - Zip Code:36559-1027
Mailing Address - Country:US
Mailing Address - Phone:251-232-1083
Mailing Address - Fax:866-291-0167
Practice Address - Street 1:8076 SPRING RUN DR
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3854
Practice Address - Country:US
Practice Address - Phone:251-232-1083
Practice Address - Fax:866-291-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4072122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6680440001Medicare NSC