Provider Demographics
NPI:1366457145
Name:BLOUGH, BRIAN ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ERIC
Last Name:BLOUGH
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 1:3440 E STATE ROAD 32 STE A2
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8769
Mailing Address - Country:US
Mailing Address - Phone:317-785-2020
Mailing Address - Fax:
Practice Address - Street 1:3440 E STATE ROAD 32 STE A2
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8769
Practice Address - Country:US
Practice Address - Phone:317-785-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096171223G0001X
NC86901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice