Provider Demographics
NPI:1740590934
Name:BLUTH, NORMAN (DDS)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:
Last Name:BLUTH
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 1:4175 SW 64TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3459
Mailing Address - Country:US
Mailing Address - Phone:954-792-3800
Mailing Address - Fax:
Practice Address - Street 1:4175 SW 64TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3459
Practice Address - Country:US
Practice Address - Phone:954-792-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072548000Medicaid