Provider Demographics
NPI:1720096076
Name:ECKERT, BLAISE C (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:C
Last Name:ECKERT
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 1:68 LEONARD STREET
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478
Mailing Address - Country:US
Mailing Address - Phone:617-484-5266
Mailing Address - Fax:617-484-2739
Practice Address - Street 1:68 LEONARD STREET
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478
Practice Address - Country:US
Practice Address - Phone:617-484-5266
Practice Address - Fax:617-484-2739
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0015432OtherTUFTS HEALTH PLAN
MA16176OtherHCHP
MA0015432OtherTUFTS HEALTH PLAN
MA16176OtherHCHP