Healthcare Provider Details

I. General information

NPI: 1982959300
Provider Name (Legal Business Name): BREANNE HAFER BLEAKMORE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4565 DRESSLER RD NW #101
CANTON OH
44718-2549
US

IV. Provider business mailing address

3793 FAIRWAY PARK DR APT 106
COPLEY OH
44321-1674
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-9457
  • Fax:
Mailing address:
  • Phone: 937-238-1585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-023718
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: