Provider Demographics
NPI:1619170339
Name:BLAGROVE, AYANA E (RDH)
Entity Type:Individual
Prefix:
First Name:AYANA
Middle Name:E
Last Name:BLAGROVE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-1087
Mailing Address - Country:US
Mailing Address - Phone:505-782-7349
Mailing Address - Fax:505-782-7405
Practice Address - Street 1:ROUTE 301 NORTH B STREET
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0467
Practice Address - Country:US
Practice Address - Phone:505-782-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH010012L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist