Provider Demographics
NPI:1861841918
Name:BLAKE, RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 S EASTERN RUN
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8070
Mailing Address - Country:US
Mailing Address - Phone:435-669-7308
Mailing Address - Fax:
Practice Address - Street 1:4425 S. MOUNTAIN ROAD
Practice Address - Street 2:STE 109
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212
Practice Address - Country:US
Practice Address - Phone:480-676-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ101611223P0221X
WA607963141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program