Provider Demographics
NPI:1184668683
Name:BLAKE, STEPHEN JOSEPH SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:BLAKE
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12162 DENTON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2504
Mailing Address - Country:US
Mailing Address - Phone:810-750-5276
Mailing Address - Fax:810-750-3722
Practice Address - Street 1:1101 W HURON ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3736
Practice Address - Country:US
Practice Address - Phone:248-681-8100
Practice Address - Fax:248-681-6318
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice