Provider Demographics
NPI:1548249907
Name:BLAZEKOVICH, ROBERT MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARK
Last Name:BLAZEKOVICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 FOREST CT
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-9703
Mailing Address - Country:US
Mailing Address - Phone:765-384-7845
Mailing Address - Fax:
Practice Address - Street 1:775 WAUKEGAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4342
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:800-434-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009213A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200245610Medicaid