Provider Demographics
NPI:1023360609
Name:BLAKE, SHANE CHRISTOPHER (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:CHRISTOPHER
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 DWIGHT ST
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-1792
Mailing Address - Country:US
Mailing Address - Phone:814-274-7262
Mailing Address - Fax:800-888-4760
Practice Address - Street 1:507 DWIGHT ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-1792
Practice Address - Country:US
Practice Address - Phone:814-274-7262
Practice Address - Fax:800-888-4760
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist