Provider Demographics
NPI:1760166599
Name:PUTMAN, BLAKE CHRISTOPHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:CHRISTOPHER
Last Name:PUTMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 COVENTRY PT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3389
Mailing Address - Country:US
Mailing Address - Phone:217-691-7848
Mailing Address - Fax:
Practice Address - Street 1:11110 FORT ST STE 106
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2183
Practice Address - Country:US
Practice Address - Phone:217-691-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-10153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist