Provider Demographics
NPI:1366765794
Name:BLAKE, CAROL ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 WISCONSIN AVE NW
Mailing Address - Street 2:SUITE 511
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2014
Mailing Address - Country:US
Mailing Address - Phone:202-966-0620
Mailing Address - Fax:202-966-1509
Practice Address - Street 1:5225 WISCONSIN AVE NW
Practice Address - Street 2:SUITE 511
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2014
Practice Address - Country:US
Practice Address - Phone:202-966-0620
Practice Address - Fax:202-966-1509
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC5133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist