Provider Demographics
NPI:1124681069
Name:BLAZE, DOCTOR MICAH J'KING (DMD)
Entity type:Individual
Prefix:DR
First Name:DOCTOR MICAH J'KING
Middle Name:
Last Name:BLAZE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MICHAEL J.
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:518 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:OH
Mailing Address - Zip Code:44405-1140
Mailing Address - Country:US
Mailing Address - Phone:513-805-3894
Mailing Address - Fax:
Practice Address - Street 1:5 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-8202
Practice Address - Country:US
Practice Address - Phone:513-721-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.026412122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice