Provider Demographics
NPI:1437348034
Name:MCRAY, BLAKE WESLEY (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:WESLEY
Last Name:MCRAY
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LINCOLN VILLAGE CIR
Mailing Address - Street 2:APT. #2141
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1611
Mailing Address - Country:US
Mailing Address - Phone:210-685-9507
Mailing Address - Fax:
Practice Address - Street 1:1309 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4645
Practice Address - Country:US
Practice Address - Phone:707-642-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234151223G0001X
CA57025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice