Provider Demographics
NPI:1235188012
Name:CHANDLER, BLAKE (DMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:CHANDLER
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 1:4004 STONEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-8300
Mailing Address - Country:US
Mailing Address - Phone:602-430-0106
Mailing Address - Fax:
Practice Address - Street 1:7409 ALCOA RD STE 5
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-6216
Practice Address - Country:US
Practice Address - Phone:602-430-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2016-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR40021223P0221X
TX307761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1235188012Medicaid
AZ721359Medicaid