Healthcare Provider Details

I. General information

NPI: 1518849603
Provider Name (Legal Business Name): NICOLE ANN BLAKE RDH/DT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LOOKOUT DR
NORTH MANKATO MN
56003-2500
US

IV. Provider business mailing address

1036 MARIE CT
NORTH MANKATO MN
56003-3437
US

V. Phone/Fax

Practice location:
  • Phone: 507-480-4646
  • Fax:
Mailing address:
  • Phone: 507-273-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT-186
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: