Provider Demographics
NPI:1871704189
Name:BLAIS, KENNETH A (DMD, MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:BLAIS
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S CARLIN SPRINGS RD STE 308
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1086
Mailing Address - Country:US
Mailing Address - Phone:703-379-2700
Mailing Address - Fax:
Practice Address - Street 1:7230 HERITAGE VILLAGE PLZ STE 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3054
Practice Address - Country:US
Practice Address - Phone:703-379-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014143401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA50988Medicaid