MEDICARE: DR. MARY THERESE BLOCK DENTIST

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	122300000X	Dentist	12009454	IN

General Provider Information

NPI Number	:	1467934505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY THERESE BLOCK DENTIST

Provider Business Mailing Address
First Line	:	528 N WALNUT ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47404-3804
Country	:	US
Telephone Number	:	812-332-8030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2507 E POPLAR DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-4327
Country	:	US
Telephone Number	:	812-322-0065
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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Directions to “ DR. MARY THERESE BLOCK DENTIST” Practice Location

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