Provider Demographics
NPI:1669694253
Name:BLAKE, SUSAN ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 JEFFERSON DR E
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-3302
Mailing Address - Country:US
Mailing Address - Phone:434-591-0168
Mailing Address - Fax:
Practice Address - Street 1:FLUVANNA CORRECTIONAL CENTER
Practice Address - Street 2:ROUTE 250 EAST
Practice Address - City:TROY
Practice Address - State:VA
Practice Address - Zip Code:22974
Practice Address - Country:US
Practice Address - Phone:434-984-3700
Practice Address - Fax:434-984-5574
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist