Provider Demographics
NPI:1912078551
Name:BLASS, ALLEN JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:JEROME
Last Name:BLASS
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 1:4920 ROSWELL RD NE
Mailing Address - Street 2:SUITE 13A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2636
Mailing Address - Country:US
Mailing Address - Phone:404-236-7222
Mailing Address - Fax:404-250-9143
Practice Address - Street 1:4920 ROSWELL RD NE
Practice Address - Street 2:SUITE 13A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2636
Practice Address - Country:US
Practice Address - Phone:404-236-7222
Practice Address - Fax:404-250-9143
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00044591AMedicaid