Provider Demographics
NPI:1720220825
Name:BLEAK, PHILLIP EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:EARL
Last Name:BLEAK
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 1:22 POWERS LN
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1432
Mailing Address - Country:US
Mailing Address - Phone:801-557-1116
Mailing Address - Fax:
Practice Address - Street 1:300 TREMONT ST STE 6
Practice Address - Street 2:
Practice Address - City:CARVER
Practice Address - State:MA
Practice Address - Zip Code:02330-1761
Practice Address - Country:US
Practice Address - Phone:801-557-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN 1855376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist