Healthcare Provider Details

I. General information

NPI: 1366765794
Provider Name (Legal Business Name): CAROL ANN BLAKE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2010
Last Update Date: 03/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 WISCONSIN AVE NW SUITE 511
WASHINGTON DC
20015-2014
US

IV. Provider business mailing address

5225 WISCONSIN AVE NW SUITE 511
WASHINGTON DC
20015-2014
US

V. Phone/Fax

Practice location:
  • Phone: 202-966-0620
  • Fax: 202-966-1509
Mailing address:
  • Phone: 202-966-0620
  • Fax: 202-966-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5133
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: