Provider Demographics
NPI:1851423313
Name:BLAKE, LAWRENCE DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DAVID
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 1:5139 RIDGEDALE DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-6115
Mailing Address - Country:US
Mailing Address - Phone:814-833-4884
Mailing Address - Fax:
Practice Address - Street 1:1745 W GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1101
Practice Address - Country:US
Practice Address - Phone:814-868-5197
Practice Address - Fax:814-868-3425
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019300-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice