Provider Demographics
NPI:1649314857
Name:BLOHMKE, CARL R (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:R
Last Name:BLOHMKE
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 1:36 GATEWAY LN
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2527
Mailing Address - Country:US
Mailing Address - Phone:631-874-4972
Mailing Address - Fax:
Practice Address - Street 1:36 GATEWAY LN
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2527
Practice Address - Country:US
Practice Address - Phone:631-874-4972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0398681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice