Provider Demographics
NPI:1578896445
Name:BLAKE, SUMMER LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:LYNN
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 1:451 MANHATTAN BEACH BLVD
Mailing Address - Street 2:SUITE #D-224
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5345
Mailing Address - Country:US
Mailing Address - Phone:310-545-0770
Mailing Address - Fax:
Practice Address - Street 1:451 MANHATTAN BEACH BLVD
Practice Address - Street 2:SUITE #D-224
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5345
Practice Address - Country:US
Practice Address - Phone:310-545-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA487031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1223X0400XOtherORTHODONTIC NPI