Provider Demographics
NPI:1073929634
Name:BURNETT, BLAKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:BURNETT
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 1:4936 MIRAMAR DR
Mailing Address - Street 2:APT. 4207
Mailing Address - City:MADEIRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-3396
Mailing Address - Country:US
Mailing Address - Phone:843-318-9525
Mailing Address - Fax:
Practice Address - Street 1:9200 113TH STREET
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708
Practice Address - Country:US
Practice Address - Phone:727-394-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program