=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013253061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZABETH BLAKE ORTHODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2012
-----------------------------------------------------
Last Update Date | 12/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 MAIN ST
-----------------------------------------------------
City | HOPKINTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01748-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-262-9532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 SILVA ST
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01757-3476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-262-9532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. ELIZABETH BLAKE PELUSO
-----------------------------------------------------
Credential | DMD, MDS
-----------------------------------------------------
Telephone | 352-262-9532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN1855332
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------