Provider Demographics
NPI:1194002196
Name:ENTRALGO, BLAKE DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:DANIEL
Last Name:ENTRALGO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560A LIPPINCOTT DRIVE
Mailing Address - Street 2:BLDG B
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-985-1800
Mailing Address - Fax:856-985-7170
Practice Address - Street 1:560A LIPPINCOTT DRIVE
Practice Address - Street 2:BLDG B
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-1800
Practice Address - Fax:856-985-7170
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02666400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist