Provider Demographics
NPI:1861641078
Name:BLAIS, MERISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MERISSA
Middle Name:
Last Name:BLAIS
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 1:77 HAVEMEYER LN
Mailing Address - Street 2:UNIT 90
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2153
Mailing Address - Country:US
Mailing Address - Phone:401-263-5113
Mailing Address - Fax:
Practice Address - Street 1:11316 76TH RD # 1
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7236
Practice Address - Country:US
Practice Address - Phone:401-762-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054501-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics