MEDICARE: MRS. YVONNE D. BLAKE-MARTIN R.D.H.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH00004141	WA

General Provider Information

NPI Number	:	1215191309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. YVONNE D. BLAKE-MARTIN R.D.H.

Provider Business Mailing Address
First Line	:	1901 E 65TH ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98404-4212
Country	:	US
Telephone Number	:	253-973-2141
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 E 65TH ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98404-4212
Country	:	US
Telephone Number	:	253-973-2141
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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