Provider Demographics
NPI:1912379926
Name:BLIMBAUM, JOSHUA LEON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:LEON
Last Name:BLIMBAUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12058 SAN JOSE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8669
Mailing Address - Country:US
Mailing Address - Phone:954-802-8061
Mailing Address - Fax:
Practice Address - Street 1:12058 SAN JOSE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8669
Practice Address - Country:US
Practice Address - Phone:904-880-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21484122300000X, 1223G0001X
AZD0093211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice