Provider Demographics
NPI:1881031946
Name:SMITH, BLAKE DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:DANIEL
Last Name:SMITH
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 1:2600 BEMIDJI AVE N
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2324
Mailing Address - Country:US
Mailing Address - Phone:218-444-7462
Mailing Address - Fax:218-751-4462
Practice Address - Street 1:2600 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2324
Practice Address - Country:US
Practice Address - Phone:218-444-7462
Practice Address - Fax:218-751-4462
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13225122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist