Provider Demographics
NPI:1912521766
Name:HULT, BLAKE (DDS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HULT
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 1:1110 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:SD
Mailing Address - Zip Code:57013-1543
Mailing Address - Country:US
Mailing Address - Phone:605-764-3179
Mailing Address - Fax:
Practice Address - Street 1:1110 W 5TH ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:SD
Practice Address - Zip Code:57013-1543
Practice Address - Country:US
Practice Address - Phone:605-764-3179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD12631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice