Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 039110 | NY |
NPI | 1003818667 |
---|---|
Provider Name | Dr. Bruce B Blau |
First Address | New York, NY 10022-1117 |
Second Address | New York, NY 10022-1117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2005 |
Last Update Date | 08/07/2007 |