Provider Demographics
NPI:1790002285
Name:BLASKO, MARY (RDH)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:BLASKO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 SE MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7251
Mailing Address - Country:US
Mailing Address - Phone:503-654-0613
Mailing Address - Fax:503-654-4087
Practice Address - Street 1:11103 SE MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7251
Practice Address - Country:US
Practice Address - Phone:503-654-0613
Practice Address - Fax:503-654-4087
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2699124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist