Provider Demographics
NPI:1255531018
Name:J BLAKE, DMD, PS
Entity type:Organization
Organization Name:J BLAKE, DMD, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:T. JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-926-1234
Mailing Address - Street 1:12615 E MISSION AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1047
Mailing Address - Country:US
Mailing Address - Phone:509-926-1234
Mailing Address - Fax:509-926-1701
Practice Address - Street 1:12615 E MISSION AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1047
Practice Address - Country:US
Practice Address - Phone:509-926-1234
Practice Address - Fax:509-926-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA105881223G0001X
WA98461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty