Provider Demographics
NPI:1386170454
Name:BLANCK, NYLE BRADLEY (DMD, MDS)
Entity type:Individual
Prefix:DR
First Name:NYLE
Middle Name:BRADLEY
Last Name:BLANCK
Suffix:
Gender:M
Credentials:DMD, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 PARK CIR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4832
Mailing Address - Country:US
Mailing Address - Phone:203-868-1981
Mailing Address - Fax:
Practice Address - Street 1:23 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1612
Practice Address - Country:US
Practice Address - Phone:203-426-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT127611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program