Provider Demographics
NPI:1275690166
Name:DR BENJAMIN E BLAKLEY DDS
Entity Type:Organization
Organization Name:DR BENJAMIN E BLAKLEY DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-257-3799
Mailing Address - Street 1:6437 RUCKER RD
Mailing Address - Street 2:6437 RUCKER RD
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-257-3799
Mailing Address - Fax:
Practice Address - Street 1:6437 RUCKER RD
Practice Address - Street 2:6437 RUCKER RD
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-257-3799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100073160AMedicaid