Healthcare Provider Details

I. General information

NPI: 1720096076
Provider Name (Legal Business Name): BLAISE C ECKERT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 LEONARD STREET
BELMONT MA
02478
US

IV. Provider business mailing address

68 LEONARD STREET
BELMONT MA
02478
US

V. Phone/Fax

Practice location:
  • Phone: 617-484-5266
  • Fax: 617-484-2739
Mailing address:
  • Phone: 617-484-5266
  • Fax: 617-484-2739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number15432
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: