Provider Demographics
NPI:1679650642
Name:BLAYLOCK, MONICA S (DDS)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:S
Last Name:BLAYLOCK
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 1:309 PIRKLE FERRY RD STE C100
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2549
Mailing Address - Country:US
Mailing Address - Phone:770-205-9226
Mailing Address - Fax:770-205-2278
Practice Address - Street 1:309 PIRKLE FERRY RD STE C100
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2549
Practice Address - Country:US
Practice Address - Phone:770-205-9226
Practice Address - Fax:770-205-2278
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA115141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11514OtherSTATE DENTAL LICENSE