MEDICARE: SHELLI BLAKE RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	14938	CA

General Provider Information

NPI Number	:	1215182613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLI BLAKE RDH

Provider Business Mailing Address
First Line	:	3242 W. 8TH STREET
Second Line	:	QUEENSCARE FAMILY CLINICS
City	:	LOS ANGELES
State	:	CA
Zip	:	90005
Country	:	US
Telephone Number	:	213-368-9779
Fax Number	:

Provider Business Practice Location Address
First Line	:	3242 W 8TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-2176
Country	:	US
Telephone Number	:	213-368-9779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2008
Last Update Date	:	11/26/2008

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