Provider Demographics
NPI:1467934505
Name:BLOCK, MARY THERESE (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:THERESE
Last Name:BLOCK
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3804
Mailing Address - Country:US
Mailing Address - Phone:812-332-8030
Mailing Address - Fax:
Practice Address - Street 1:2507 E POPLAR DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4327
Practice Address - Country:US
Practice Address - Phone:812-322-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist