Provider Demographics
NPI:1770993180
Name:BLAKE M. BULLARD, D.D.S., P.L.L.C.
Entity type:Organization
Organization Name:BLAKE M. BULLARD, D.D.S., P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-931-3366
Mailing Address - Street 1:5008 W. UNIVERSITY BLVD.
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2978
Mailing Address - Country:US
Mailing Address - Phone:580-931-3366
Mailing Address - Fax:580-931-3390
Practice Address - Street 1:5008 W. UNIVERSITY BLVD.
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2978
Practice Address - Country:US
Practice Address - Phone:580-931-3366
Practice Address - Fax:580-931-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6022122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty