Provider Demographics
NPI:1043772742
Name:WILLOUGHBY, BLAKE JAMES II (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:JAMES
Last Name:WILLOUGHBY
Suffix:II
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 1:63 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-2125
Mailing Address - Country:US
Mailing Address - Phone:636-236-3177
Mailing Address - Fax:
Practice Address - Street 1:3400 BURNS RD STE 100
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4352
Practice Address - Country:US
Practice Address - Phone:561-627-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN245341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program