Provider Demographics
NPI:1821012535
Name:BLAKE, HENRY CHRISTOPHER III (DDS)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:CHRISTOPHER
Last Name:BLAKE
Suffix:III
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 1:1802A NEW HANOVER MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5350
Mailing Address - Country:US
Mailing Address - Phone:910-762-8245
Mailing Address - Fax:910-763-0293
Practice Address - Street 1:1802A NEW HANOVER MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5350
Practice Address - Country:US
Practice Address - Phone:910-762-8245
Practice Address - Fax:910-763-0293
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC51271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-90804Medicaid
NCU36941Medicare UPIN