Provider Demographics
NPI:1588611768
Name:BLOUGH, LELAND S JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LELAND
Middle Name:S
Last Name:BLOUGH
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:33 COLLEGE HILL RD
Mailing Address - Street 2:BLDG #5, SUITE 5A
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2776
Mailing Address - Country:US
Mailing Address - Phone:401-828-3688
Mailing Address - Fax:
Practice Address - Street 1:33 COLLEGE HILL RD
Practice Address - Street 2:BLDG #5, SUITE 5A
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2776
Practice Address - Country:US
Practice Address - Phone:401-828-3688
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI24551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU50129Medicare UPIN