Basic Information
| Provider Information | |||||||||
| NPI: | 1598177222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONALDSON | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MCHUGH BLVD | ||||||||
| Address2: | COMMANDING OFFICER 2D DENBN/NDC PSC 20130 | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285400130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MCHUGH BLVD | ||||||||
| Address2: | COMMANDING OFFICER 2D DENBN/NDC PSC 20130 | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285400130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | 9068875-9921 | UT | Y | Dental Providers | Dentist | Endodontics |
No ID Information.