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General NPI Number Information
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NPI Number | 1124681069
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Entity Type | Individual
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Provider Name | DOCTOR MICAH J'KING BLAZE DMD
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Gender | Male
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Dates
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Enumeration Date | 04/16/2019
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 5 E LIBERTY ST
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City | CINCINNATI
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State | OH
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Zip | 45202-8202
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Country | US
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Telephone | 513-721-6060
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Fax |
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Provider Business Mailing Address
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Address Line | 518 6TH ST
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City | CAMPBELL
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State | OH
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Zip | 44405-1140
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Country | US
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Telephone | 513-805-3894
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30.026412
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30.026412
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License Number State | OH
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