Provider Demographics
NPI:1548203706
Name:BLAKLEY, RAYMOND EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:EARL
Last Name:BLAKLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 402
Mailing Address - Street 2:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Mailing Address - City:APO AE
Mailing Address - State:NY
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:637-192-9130
Mailing Address - Fax:
Practice Address - Street 1:CMR 402
Practice Address - Street 2:LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE
Practice Address - City:APO AE
Practice Address - State:NY
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:637-192-9130
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0149091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice