Provider Demographics
NPI:1356414080
Name:BLUM, FRED G (DMD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:G
Last Name:BLUM
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 1:890 WINTON RD S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-1636
Mailing Address - Country:US
Mailing Address - Phone:585-461-1670
Mailing Address - Fax:585-461-1058
Practice Address - Street 1:890 WINTON RD S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1636
Practice Address - Country:US
Practice Address - Phone:585-461-1670
Practice Address - Fax:585-461-1058
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01210911Medicaid