Provider Demographics
NPI:1972714707
Name:SCOTT, BLAKE WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:WILLIAM
Last Name:SCOTT
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 1:6333 LA JOLLA BLVD
Mailing Address - Street 2:UNIT 271
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-6615
Mailing Address - Country:US
Mailing Address - Phone:415-517-6729
Mailing Address - Fax:
Practice Address - Street 1:13128 14TH ST
Practice Address - Street 2:FIRST DENTAL BATTALION NDC
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-5578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program