Provider Demographics
NPI:1558332056
Name:ED BLANTON, DDS, PA
Entity Type:Organization
Organization Name:ED BLANTON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ESMOND
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-728-6600
Mailing Address - Street 1:2149 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2541
Mailing Address - Country:US
Mailing Address - Phone:352-728-6600
Mailing Address - Fax:352-728-0585
Practice Address - Street 1:2149 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2541
Practice Address - Country:US
Practice Address - Phone:352-728-6600
Practice Address - Fax:352-728-0585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00078201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6571Medicare ID - Type Unspecified