Provider Demographics
NPI:1639686736
Name:BRANDON BLAKE DDS PA
Entity Type:Organization
Organization Name:BRANDON BLAKE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:828-442-3206
Mailing Address - Street 1:122 HARDEES LN
Mailing Address - Street 2:
Mailing Address - City:BANNER ELK
Mailing Address - State:NC
Mailing Address - Zip Code:28604-9683
Mailing Address - Country:US
Mailing Address - Phone:828-898-4656
Mailing Address - Fax:
Practice Address - Street 1:122 HARDEES LN
Practice Address - Street 2:
Practice Address - City:BANNER ELK
Practice Address - State:NC
Practice Address - Zip Code:28604-9683
Practice Address - Country:US
Practice Address - Phone:828-898-4656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8380261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental