Provider Demographics
NPI:1225622830
Name:MA, BLAKE (DMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MA
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 1:22 LATHAM RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-1914
Mailing Address - Country:US
Mailing Address - Phone:860-341-6441
Mailing Address - Fax:
Practice Address - Street 1:1355 MIDDLETOWN AVE
Practice Address - Street 2:
Practice Address - City:NORTHFORD
Practice Address - State:CT
Practice Address - Zip Code:06472-1382
Practice Address - Country:US
Practice Address - Phone:203-484-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT133681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice