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General NPI Number Information
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NPI Number | 1386170454
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Entity Type | Individual
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Provider Name | NYLE BRADLEY BLANCK D.M.D., M.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/10/2017
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Last Update Date | 06/15/2021
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Provider Practice Location Address
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Address Line | 23 CHURCH HILL RD
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City | NEWTOWN
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State | CT
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Zip | 06470-1612
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Country | US
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Telephone | 203-426-5900
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Fax |
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Provider Business Mailing Address
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Address Line | 38 PARK CIR
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City | MILFORD
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State | CT
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Zip | 06460-4832
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Country | US
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Telephone | 203-868-1981
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12761
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License Number State | CT
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