Provider Demographics
NPI:1104276518
Name:BLAKE-IRELAND, THERESA MARIE (RDH)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:BLAKE-IRELAND
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6636
Mailing Address - Country:US
Mailing Address - Phone:207-872-8891
Mailing Address - Fax:
Practice Address - Street 1:93 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6636
Practice Address - Country:US
Practice Address - Phone:207-872-8891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3040124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist