Provider Demographics
NPI:1821178070
Name:BLAKE, JR, ERNEST HUBBERT (DDS)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:HUBBERT
Last Name:BLAKE, JR
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 1:535 JOHN KNOX RD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-4117
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:850-298-6050
Practice Address - Street 1:409 E ASH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2104
Practice Address - Country:US
Practice Address - Phone:850-223-2578
Practice Address - Fax:850-223-3047
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-12127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071572700Medicaid