Healthcare Provider Details

I. General information

NPI: 1629837802
Provider Name (Legal Business Name): SABRINA ROSE BLASKOVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 ELMWOOD AVE
ROCHESTER NY
14620-2913
US

IV. Provider business mailing address

15712 22ND AVE
WHITESTONE NY
11357-3911
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5051
  • Fax:
Mailing address:
  • Phone: 347-804-7298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number065490
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: