Provider Demographics
NPI:1598707713
Name:DENTON CENTER LLC
Entity Type:Organization
Organization Name:DENTON CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BLASE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:336-625-1750
Mailing Address - Street 1:1273 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27205-2625
Mailing Address - Country:US
Mailing Address - Phone:336-736-8195
Mailing Address - Fax:336-498-8522
Practice Address - Street 1:1273 CEDAR CREEK DR
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27205-2625
Practice Address - Country:US
Practice Address - Phone:336-736-8195
Practice Address - Fax:336-498-8522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23878261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909430Medicaid
NC89012J1Medicaid
NC2335721Medicare PIN