Healthcare Provider Details

I. General information

NPI: 1801275946
Provider Name (Legal Business Name): MELISSA KATHLEEN BLAKE D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3154 S CHURCH ST
BURLINGTON NC
27215-9114
US

IV. Provider business mailing address

4834 FLEETWOOD CIR
WINSTON SALEM NC
27106-4253
US

V. Phone/Fax

Practice location:
  • Phone: 336-524-5439
  • Fax:
Mailing address:
  • Phone: 774-251-1137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberNC10725
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: