Provider Demographics
NPI:1407054174
Name:BLAKE, ELIZABETH CLAIR (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:CLAIR
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 FRANKLIN ST APT B
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1785
Mailing Address - Country:US
Mailing Address - Phone:352-262-9532
Mailing Address - Fax:
Practice Address - Street 1:175 LITTLETON RD
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3196
Practice Address - Country:US
Practice Address - Phone:978-392-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 17644390200000X
MADN18553321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program