Basic Information
| Provider Information | |||||||||
| NPI: | 1225643307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAHNIK | ||||||||
| FirstName: | BRICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 73856 SUNNYVALE DR APT B | ||||||||
| Address2: | |||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922777114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9526936597 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 ST DENTAL BATTALION/NAVAL DENTAL CENTER ATTN: MEDICAL | ||||||||
| Address2: | BLDG 2238 A AVE CAMP PENDLETON, CA. 92055-5221 | ||||||||
| City: | FPO | ||||||||
| State: | AA | ||||||||
| PostalCode: | 920555221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2020 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D14445 | MN | Y | Dental Providers | Dentist |
No ID Information.