Provider Demographics
NPI:1609155498
Name:BLAKLEY, ALICIA NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:NICOLE
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6914
Mailing Address - Country:US
Mailing Address - Phone:920-838-1649
Mailing Address - Fax:
Practice Address - Street 1:8200 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2552
Practice Address - Country:US
Practice Address - Phone:414-760-3900
Practice Address - Fax:414-464-7258
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70311223G0001X
IL0190287211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty