Provider Demographics
NPI:1669517330
Name:BLAKE, THOMAS R (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
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 1:2409 FAIROAK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-2301
Mailing Address - Country:US
Mailing Address - Phone:260-747-5745
Mailing Address - Fax:
Practice Address - Street 1:2409 FAIROAK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-2301
Practice Address - Country:US
Practice Address - Phone:260-747-5745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN79731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN777279OtherUNITED CONCORDIA
IN1091OtherPHP