Healthcare Provider Details

I. General information

NPI: 1669694253
Provider Name (Legal Business Name): SUSAN ELIZABETH BLAKE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FLUVANNA CORRECTIONAL CENTER ROUTE 250 EAST
TROY VA
22974
US

IV. Provider business mailing address

852 JEFFERSON DR E
PALMYRA VA
22963-3302
US

V. Phone/Fax

Practice location:
  • Phone: 434-984-3700
  • Fax: 434-984-5574
Mailing address:
  • Phone: 434-591-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401008275
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: