Healthcare Provider Details

I. General information

NPI: 1467463521
Provider Name (Legal Business Name): BLAKE E. MARSTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 CARMEL MOUNTAIN RD SUITE D
SAN DIEGO CA
92129-2157
US

IV. Provider business mailing address

9330 CARMEL MOUNTAIN RD SUITE D
SAN DIEGO CA
92129-2157
US

V. Phone/Fax

Practice location:
  • Phone: 858-484-6100
  • Fax: 858-484-8601
Mailing address:
  • Phone: 858-484-6100
  • Fax: 858-484-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD6621
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number55966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: