Provider Demographics
NPI:1528173531
Name:BLAIN DENTISTRY PC
Entity type:Organization
Organization Name:BLAIN DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:MAJORIE
Authorized Official - Last Name:BLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-282-5100
Mailing Address - Street 1:1311 JACKSON AVE
Mailing Address - Street 2:#10D
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5436
Mailing Address - Country:US
Mailing Address - Phone:516-282-5100
Mailing Address - Fax:
Practice Address - Street 1:229 POST AVE
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-3021
Practice Address - Country:US
Practice Address - Phone:516-282-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0242008Medicaid