Healthcare Provider Details

I. General information

NPI: 1215191309
Provider Name (Legal Business Name): YVONNE D. BLAKE-MARTIN R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 E 65TH ST
TACOMA WA
98404-4212
US

IV. Provider business mailing address

1901 E 65TH ST
TACOMA WA
98404-4212
US

V. Phone/Fax

Practice location:
  • Phone: 253-973-2141
  • Fax:
Mailing address:
  • Phone: 253-973-2141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH00004141
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: