Provider Demographics
NPI:1720341506
Name:CAMERON, BLAKE S (DDS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:S
Last Name:CAMERON
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 1:170 E 1400 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2379
Mailing Address - Country:US
Mailing Address - Phone:435-753-5166
Mailing Address - Fax:435-787-1741
Practice Address - Street 1:170 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2379
Practice Address - Country:US
Practice Address - Phone:435-753-4400
Practice Address - Fax:435-787-1741
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT83537019922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist