Provider Demographics
NPI:1568473312
Name:BLAKE, PATRICIA (DDS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1694 W HIBISCUS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1421 MALABAR RD NE
Practice Address - Street 2:SUITE 240
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2576
Practice Address - Country:US
Practice Address - Phone:321-722-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice