Provider Demographics
NPI:1710671797
Name:ROST, BLAKE THOMAS (DMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:THOMAS
Last Name:ROST
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 1:1081 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2448
Mailing Address - Country:US
Mailing Address - Phone:573-426-4455
Mailing Address - Fax:573-426-6723
Practice Address - Street 1:509 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3302
Practice Address - Country:US
Practice Address - Phone:573-426-4455
Practice Address - Fax:573-426-6723
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023020437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist