Provider Demographics
NPI:1619966439
Name:BLAIN, CARLA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:M
Last Name:BLAIN
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 1:1311 JACKSON AVE
Mailing Address - Street 2:APT 10D
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5436
Mailing Address - Country:US
Mailing Address - Phone:516-425-3076
Mailing Address - Fax:
Practice Address - Street 1:229 POST AVE
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-3021
Practice Address - Country:US
Practice Address - Phone:516-282-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0507591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02420088Medicaid