Basic Information
| Provider Information | |||||||||
| NPI: | 1952552002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | LEONICIA | ||||||||
| MiddleName: | RASCHEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8101 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162297440 | ||||||||
| FaxNumber: | 2162292501 | ||||||||
| Practice Location | |||||||||
| Address1: | 8101 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162297440 | ||||||||
| FaxNumber: | 2162292501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 30-022848 | OH | Y | Dental Providers | Dentist | General Practice | 1223G0001X | 24502 | TX | N | Dental Providers | Dentist | General Practice |
No ID Information.