Provider Demographics
NPI:1649328782
Name:BLAKE, CLINTON LARRY (DDS)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:LARRY
Last Name:BLAKE
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 1:2820 NW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-6576
Mailing Address - Country:US
Mailing Address - Phone:405-392-4883
Mailing Address - Fax:405-392-4889
Practice Address - Street 1:831 SIENA SPRINGS DR.
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071
Practice Address - Country:US
Practice Address - Phone:405-392-4883
Practice Address - Fax:405-392-4889
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4950075-99221223G0001X
OK63301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice