Provider Demographics
NPI:1336765452
Name:BLADES, JACEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JACEE
Middle Name:
Last Name:BLADES
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 1:2030 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3116
Mailing Address - Country:US
Mailing Address - Phone:985-626-3338
Mailing Address - Fax:
Practice Address - Street 1:2030 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3116
Practice Address - Country:US
Practice Address - Phone:985-626-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA71081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7108OtherLA STATE BOARD OF DENTISTRY