Provider Demographics
NPI:1881200673
Name:BOLEWARE, BLAKE DENTON (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:DENTON
Last Name:BOLEWARE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 THOMASTOWN LN STE A
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3440
Mailing Address - Country:US
Mailing Address - Phone:601-856-3054
Mailing Address - Fax:
Practice Address - Street 1:525 THOMASTOWN LN STE A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3440
Practice Address - Country:US
Practice Address - Phone:601-856-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOR-575-201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics