Provider Demographics
NPI:1801275946
Name:BLAKE, MELISSA KATHLEEN (DMD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:KATHLEEN
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 1:123 EVANS MILL LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3555
Mailing Address - Country:US
Mailing Address - Phone:774-251-1137
Mailing Address - Fax:
Practice Address - Street 1:1924 ROUTE 70 E
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003
Practice Address - Country:US
Practice Address - Phone:856-783-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC107251223P0221X
390200000X
NJ22DI027673001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program