Provider Demographics
NPI:1568912426
Name:J.BLAKE PERKINS D.D.S. P.S.
Entity Type:Organization
Organization Name:J.BLAKE PERKINS D.D.S. P.S.
Other - Org Name:NEW IMAGE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-604-7151
Mailing Address - Street 1:811 NE 112TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5115
Mailing Address - Country:US
Mailing Address - Phone:360-604-7151
Mailing Address - Fax:360-597-4562
Practice Address - Street 1:811 NE 112TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5115
Practice Address - Country:US
Practice Address - Phone:360-604-7151
Practice Address - Fax:360-597-4562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104084276OtherDME ONLY FOR MEDICARE