Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2696 | CO |
NPI | 1073862306 |
---|---|
Provider Name | Maryellen Blasing |
First Address | Pueblo, CO 81005-2617 |
Second Address | Pueblo, CO 81005-2617 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2012 |
Last Update Date | 31/08/2012 |