Healthcare Provider Details

I. General information

NPI: 1013253061
Provider Name (Legal Business Name): ELIZABETH BLAKE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2012
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MAIN ST
HOPKINTON MA
01748-3118
US

IV. Provider business mailing address

2 SILVA ST
MILFORD MA
01757-3476
US

V. Phone/Fax

Practice location:
  • Phone: 352-262-9532
  • Fax:
Mailing address:
  • Phone: 352-262-9532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1855332
License Number StateMA

VIII. Authorized Official

Name: DR. ELIZABETH BLAKE PELUSO
Title or Position: ORTHODONTIST
Credential: DMD, MDS
Phone: 352-262-9532