Provider Demographics
NPI:1104120708
Name:BLAIS, ADAM MATTHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:MATTHEW
Last Name:BLAIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 LORING DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4483
Mailing Address - Country:US
Mailing Address - Phone:860-301-7681
Mailing Address - Fax:
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDNOT LICENSED YET1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice