Healthcare Provider Details

I. General information

NPI: 1750575163
Provider Name (Legal Business Name): BLAKE JEREMY MAXFIELD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 12TH ST
RICHMOND VA
23298-5064
US

IV. Provider business mailing address

520 N 12TH ST
RICHMOND VA
23298-5064
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-0843
  • Fax:
Mailing address:
  • Phone: 804-828-0843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: