Provider Demographics
NPI:1750868915
Name:BLAKE FERANDO DMD LLC
Entity type:Organization
Organization Name:BLAKE FERANDO DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FERANDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-978-6400
Mailing Address - Street 1:346 FORT ZUMWALT SQ
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3065
Mailing Address - Country:US
Mailing Address - Phone:636-978-6400
Mailing Address - Fax:
Practice Address - Street 1:346 FORT ZUMWALT SQ
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3065
Practice Address - Country:US
Practice Address - Phone:636-978-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180153571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty