Provider Demographics
NPI:1720081268
Name:BLAKE, GEORGE DALE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DALE
Last Name:BLAKE
Suffix:JR
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 1:229 HALF MOON WAY
Mailing Address - Street 2:
Mailing Address - City:RUNAWAY BAY
Mailing Address - State:TX
Mailing Address - Zip Code:76426-9773
Mailing Address - Country:US
Mailing Address - Phone:940-575-4185
Mailing Address - Fax:
Practice Address - Street 1:229 HALF MOON WAY
Practice Address - Street 2:
Practice Address - City:RUNAWAY BAY
Practice Address - State:TX
Practice Address - Zip Code:76426-9773
Practice Address - Country:US
Practice Address - Phone:940-575-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice