Provider Demographics
NPI:1356442446
Name:BLAKE, ROBERT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:BLAKE
Suffix:
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 1:3 LANTHORN LN
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4721
Mailing Address - Country:US
Mailing Address - Phone:978-927-7686
Mailing Address - Fax:
Practice Address - Street 1:50 WEST ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2228
Practice Address - Country:US
Practice Address - Phone:978-927-3515
Practice Address - Fax:978-927-7686
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice