Provider Demographics
NPI:1497742720
Name:DENNIS, R. BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:BLAKE
Last Name:DENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 CHUCK DAWLEY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4183
Mailing Address - Country:US
Mailing Address - Phone:843-849-1551
Mailing Address - Fax:843-884-0629
Practice Address - Street 1:1106 CHUCK DAWLEY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4183
Practice Address - Country:US
Practice Address - Phone:843-849-1551
Practice Address - Fax:843-884-0629
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12163207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0683Medicaid
SCGP2895Medicaid
SCD99112Medicare UPIN
SCDM0683Medicaid
SC0181260001Medicare NSC
SCCA6815Medicare PIN
SC2216Medicare PIN