Provider Demographics
NPI:1780930073
Name:BLASKOVICH, MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BLASKOVICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007
Mailing Address - Country:US
Mailing Address - Phone:719-647-9433
Mailing Address - Fax:
Practice Address - Street 1:120 S CRESCENT DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-2787
Practice Address - Country:US
Practice Address - Phone:719-647-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX282481223G0001X
CODEN.002018771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice