Provider Demographics
NPI:1952552002
Name:BLUE, LEONICIA RASCHEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEONICIA
Middle Name:RASCHEL
Last Name:BLUE
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 1:2501 CHATHAM RD STE 4031
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4188
Mailing Address - Country:US
Mailing Address - Phone:234-400-9199
Mailing Address - Fax:216-229-2501
Practice Address - Street 1:6725 W CENTRAL AVE STE M111
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1148
Practice Address - Country:US
Practice Address - Phone:623-434-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX245021223G0001X
OH30-0228481223G0001X
VA04014180361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice