Provider Demographics
NPI:1740859867
Name:DANIEL R. BLAZO, DDS, PLLC
Entity type:Organization
Organization Name:DANIEL R. BLAZO, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-505-0985
Mailing Address - Street 1:22100 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3932
Mailing Address - Country:US
Mailing Address - Phone:313-563-5855
Mailing Address - Fax:313-563-5865
Practice Address - Street 1:22100 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3932
Practice Address - Country:US
Practice Address - Phone:313-563-5855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental