Provider Demographics
NPI:1578647426
Name:BLUE, DENNIS ROYAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:ROYAL
Last Name:BLUE
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 1:3144 BROADWAY ST # 4-265
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3838
Mailing Address - Country:US
Mailing Address - Phone:707-338-6504
Mailing Address - Fax:
Practice Address - Street 1:3144 BROADWAY ST # 4-265
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3838
Practice Address - Country:US
Practice Address - Phone:707-338-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA243631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice