Provider Demographics
NPI:1740522333
Name:BLAKE KINGSBURY DMD PLLC
Entity type:Organization
Organization Name:BLAKE KINGSBURY DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:CARSON
Authorized Official - Last Name:KINGSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-854-8887
Mailing Address - Street 1:2557 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4712
Mailing Address - Country:US
Mailing Address - Phone:704-854-8887
Mailing Address - Fax:704-854-8893
Practice Address - Street 1:2557 PEMBROKE RD
Practice Address - Street 2:2557 PEMBROKE RD
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4712
Practice Address - Country:US
Practice Address - Phone:704-854-8887
Practice Address - Fax:704-854-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831338276OtherDENTAL