Provider Demographics
NPI:1679914782
Name:CAROL A BLAKE, DDS, PLLC
Entity Type:Organization
Organization Name:CAROL A BLAKE, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-966-0620
Mailing Address - Street 1:5225 WISCONSIN AVE NW
Mailing Address - Street 2:SUITE 511
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2014
Mailing Address - Country:US
Mailing Address - Phone:202-966-0620
Mailing Address - Fax:202-966-1509
Practice Address - Street 1:5225 WISCONSIN AVE NW
Practice Address - Street 2:SUITE 511
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2014
Practice Address - Country:US
Practice Address - Phone:202-966-0620
Practice Address - Fax:202-966-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC5133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty