Provider Demographics
NPI:1508937061
Name:BLUM, MARSHALL S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:S
Last Name:BLUM
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 1:317 E MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2818
Mailing Address - Country:US
Mailing Address - Phone:631-361-7030
Mailing Address - Fax:631-724-1361
Practice Address - Street 1:317 MIDDLE COUNTRY ROAD
Practice Address - Street 2:SUITE 8
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2818
Practice Address - Country:US
Practice Address - Phone:631-361-7030
Practice Address - Fax:631-724-1361
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0272621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00281618Medicaid
AB1765809OtherDEA NUMBER