Provider Demographics
NPI:1558694117
Name:ALAN M. BLAKE D.D.S.
Entity Type:Organization
Organization Name:ALAN M. BLAKE D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-362-5454
Mailing Address - Street 1:808 N. 9TH ST.
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334
Mailing Address - Country:US
Mailing Address - Phone:712-362-5454
Mailing Address - Fax:712-362-4737
Practice Address - Street 1:808 N. 9TH ST.
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334
Practice Address - Country:US
Practice Address - Phone:712-362-5454
Practice Address - Fax:712-362-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA060081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty