Provider Demographics
NPI:1588831275
Name:MISTY HORN-BLAKE D.D.S PC
Entity Type:Organization
Organization Name:MISTY HORN-BLAKE D.D.S PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HORN-BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-283-8830
Mailing Address - Street 1:1301 SUNSET DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7906
Mailing Address - Country:US
Mailing Address - Phone:423-283-8830
Mailing Address - Fax:423-283-8820
Practice Address - Street 1:1301 SUNSET DR
Practice Address - Street 2:SUITE 6
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7906
Practice Address - Country:US
Practice Address - Phone:423-283-8830
Practice Address - Fax:423-283-8820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN87281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty