Provider Demographics
NPI:1174511604
Name:BLEN, MICHAEL D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:BLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6363 POPLAR AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4831
Mailing Address - Country:US
Mailing Address - Phone:901-415-2536
Mailing Address - Fax:901-415-6292
Practice Address - Street 1:6363 POPLAR AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4831
Practice Address - Country:US
Practice Address - Phone:901-415-2536
Practice Address - Fax:901-415-6292
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDS73181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0016888Medicaid