Provider Demographics
NPI:1770708851
Name:WALROND, BLAKE SCOTT (DDS PA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:SCOTT
Last Name:WALROND
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27313
Mailing Address - Country:US
Mailing Address - Phone:336-674-2328
Mailing Address - Fax:336-674-7158
Practice Address - Street 1:2607 TABERNACLE CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:PLEASANT GARDEN
Practice Address - State:NC
Practice Address - Zip Code:27313
Practice Address - Country:US
Practice Address - Phone:336-674-2328
Practice Address - Fax:336-674-7158
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice