Provider Demographics
NPI:1871149120
Name:BLANCO, DAMIEN PHILLIPS (DMD)
Entity type:Individual
Prefix:DR
First Name:DAMIEN
Middle Name:PHILLIPS
Last Name:BLANCO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5981 BENT PINE DR APT 1728
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-3392
Mailing Address - Country:US
Mailing Address - Phone:305-742-3345
Mailing Address - Fax:
Practice Address - Street 1:275 S CHICKASAW TRL STE 2
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3505
Practice Address - Country:US
Practice Address - Phone:407-434-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN245081223G0001X
TX357981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice