Provider Demographics
NPI:1659903235
Name:BLAZQUEZ-GOMEZ, MARIA JOSE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JOSE
Last Name:BLAZQUEZ-GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4TH AND INNER LOOP ROAD
Mailing Address - Street 2:BLDG 171
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310
Mailing Address - Country:US
Mailing Address - Phone:719-526-5537
Mailing Address - Fax:719-524-2843
Practice Address - Street 1:4TH AND INNER LOOP ROAD
Practice Address - Street 2:BLDG 171
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:719-524-2843
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant