Provider Demographics
NPI:1558884742
Name:RICHARD, BLAKE WALKER (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:WALKER
Last Name:RICHARD
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 1:3204 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7908
Mailing Address - Country:US
Mailing Address - Phone:318-267-4479
Mailing Address - Fax:
Practice Address - Street 1:2947 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6952
Practice Address - Country:US
Practice Address - Phone:214-381-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist