Provider Demographics
NPI:1629517719
Name:TOLLISON, BLAKE LEWIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:LEWIS
Last Name:TOLLISON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S. TWINING ST
Mailing Address - Street 2:BUILDING 760
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S. TWINING ST
Practice Address - Street 2:BUILDING 760
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8950122300000X
ALD.6883-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist