Provider Demographics
NPI:1558701177
Name:RICHARD W BLAKE DDS PA
Entity Type:Organization
Organization Name:RICHARD W BLAKE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1904-743-2000
Mailing Address - Street 1:943 CESERY BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5655
Mailing Address - Country:US
Mailing Address - Phone:904-743-2000
Mailing Address - Fax:904-744-0598
Practice Address - Street 1:943 CESERY BLVD STE D
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5655
Practice Address - Country:US
Practice Address - Phone:904-743-2000
Practice Address - Fax:904-744-0598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00056341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074223600Medicaid