Provider Demographics
NPI:1376195636
Name:BARRY-BLOCKER, AISSATOU
Entity Type:Individual
Prefix:
First Name:AISSATOU
Middle Name:
Last Name:BARRY-BLOCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD # D11-6
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0428
Mailing Address - Country:US
Mailing Address - Phone:352-273-7631
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD # D11-6
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-5865
Practice Address - Country:US
Practice Address - Phone:352-273-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.0006684-C1122300000X
FLDRPM23291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist