Provider Demographics
NPI:1689300659
Name:MIKESELL, BLAKE CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:CHARLES
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9639 CURRIE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9143
Mailing Address - Country:US
Mailing Address - Phone:231-360-7138
Mailing Address - Fax:
Practice Address - Street 1:1955 N PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3157
Practice Address - Country:US
Practice Address - Phone:248-669-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist