Provider Demographics
NPI:1932388600
Name:BLAKELY, MAURICE WELBORN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:WELBORN
Last Name:BLAKELY
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 1:1519 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1437
Mailing Address - Country:US
Mailing Address - Phone:410-962-1617
Mailing Address - Fax:410-962-1512
Practice Address - Street 1:1519 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1437
Practice Address - Country:US
Practice Address - Phone:410-962-1617
Practice Address - Fax:410-962-1512
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD62101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice