Provider Demographics
NPI:1124374111
Name:BLAKELY, ANCELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANCELA
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 PANTHER LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1405
Mailing Address - Country:US
Mailing Address - Phone:443-995-0533
Mailing Address - Fax:
Practice Address - Street 1:2511 PANTHER LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1405
Practice Address - Country:US
Practice Address - Phone:443-995-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14584122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist