Provider Demographics
NPI:1902114515
Name:BORELLO, BLAKE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:BORELLO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 SAINT CHARLES ST
Mailing Address - Street 2:APT. 5A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1963
Mailing Address - Country:US
Mailing Address - Phone:636-625-4224
Mailing Address - Fax:314-845-1864
Practice Address - Street 1:6288 RONALD REAGAN DR.
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-625-4224
Practice Address - Fax:314-845-1864
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080196441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics