=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265040539
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE RAMOS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2020
-----------------------------------------------------
Last Update Date | 07/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 W LAKE LANSING RD
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-333-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3846 CALYPSO RD
-----------------------------------------------------
City | HOLT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48842-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-803-0844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901600600
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------