Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN 17164 | FL |
NPI | 1003008723 |
---|---|
Provider Name | Dr. Teddy Roger Bland JR. |
First Address | Eustis, FL 32726-4343 |
Second Address | Eustis, FL 32726-4343 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2007 |
Last Update Date | 31/03/2008 |