Provider Demographics
NPI:1962679563
Name:SHOWALTER, BLAKE B (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:B
Last Name:SHOWALTER
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 1:2616 W BEEBE CAPPS EXPY
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4968
Mailing Address - Country:US
Mailing Address - Phone:501-268-8669
Mailing Address - Fax:
Practice Address - Street 1:2616 W BEEBE CAPPS EXPY
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4968
Practice Address - Country:US
Practice Address - Phone:501-268-8669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR36681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice