Blake Denton Boleware, DMD, MS
Individual provider Active NPI Orthodontics and Dentofacial Orthopedics Dentistry · Ridgeland, MS
NPI 1881200673 · NPPES record last updated Aug 14, 2023
Key facts
- NPI
- 1881200673
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry 1223X0400X
- License
- OR-575-20 (MS)
- Practice address
- 525 Thomastown LN Ste a
Ridgeland, MS 39157-3440 - Phone
- (601) 856-3054
- NPI assigned
- Sep 17, 2020
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OR-575-20 | MS | MD | Orthodontics and Dentofacial Orthopedic Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| S Everett Rushing, DMD,PA | Orthodontics and Dentofacial Orthopedics | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | OR-575-20 | MS | Yes |
Addresses
Primary practice location
525 Thomastown LN Ste a
Ridgeland, MS 39157-3440
Mailing address
525 Thomastown LN Ste a
Ridgeland, MS 39157-3440
Phone (601) 856-3054
Other practice location 1
2685 Crane Ridge Dr Ste A
Jackson, MS 39216-4906
Phone (601) 981-3036
Other practice location 2
749 Clinton Pkwy
Clinton, MS 39056-5245
Phone (601) 926-1772
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Other URL | vassar.cloud9ortho.com | Direct |
Other providers in Ridgeland, MS
- Boatox LLC
- Carolyn B Bohnsack Shepard
- Marquitta Bolden
- Tyler E Bolden
- Boldens Dependable Private Sitting LLC
- Hayley Boleware
- Gary Glenn Bolton
- Bond Pharmacy Inc
- Bond Pharmacy Inc.
- Darryl James Bonds II
All providers in Ridgeland, MS · Orthodontics and Dentofacial Orthopedics Dentistry in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 14, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.