Provider Demographics
NPI:1831499532
Name:BLAKE, CHRISTOPHER ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ALLEN
Last Name:BLAKE
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 1:17280 W NORTH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-789-9200
Mailing Address - Fax:262-789-9213
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-789-9200
Practice Address - Fax:262-789-9213
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50020970151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice