MEDICARE: RONDELL L. BLAKEY, D.D.S., P.A.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8515	NC

General Provider Information

NPI Number	:	1558684985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RONDELL L. BLAKEY, D.D.S., P.A.

Provider Business Mailing Address
First Line	:	2621 GARDEN HILL DR APT 108
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-6522
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2621 GARDEN HILL DR APT 108
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-6522
Country	:	US
Telephone Number	:	919-435-0632
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONDELL LUCIAN BLAKEY
Credential	:	D.D.S.
Telephone Number	:	919-435-0632

Provider Enumeration Date	:	03/12/2010
Last Update Date	:	03/12/2010

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