Provider Demographics
NPI:1003485624
Name:BLAKE, TERRY MICHAEL (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:MICHAEL
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
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Mailing Address - Street 1:225 SOUTH MAIN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:O'FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366
Mailing Address - Country:US
Mailing Address - Phone:636-272-6666
Mailing Address - Fax:636-272-6661
Practice Address - Street 1:225 SOUTH MAIN
Practice Address - Street 2:SUITE 101
Practice Address - City:O'FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366
Practice Address - Country:US
Practice Address - Phone:636-272-6666
Practice Address - Fax:636-272-6661
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO0115741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics