Provider Demographics
NPI:1265761639
Name:WESTRA, BLAKE (DMD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:WESTRA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2938
Mailing Address - Country:US
Mailing Address - Phone:217-348-7770
Mailing Address - Fax:217-348-9729
Practice Address - Street 1:903 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2938
Practice Address - Country:US
Practice Address - Phone:217-348-7770
Practice Address - Fax:217-348-9729
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist