MEDICARE: DR. BLAKE RYAN ADAMS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6018	OK

General Provider Information

NPI Number	:	1164684676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE RYAN ADAMS DDS

Provider Business Mailing Address
First Line	:	15417 IVY HILL DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-9341
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3401 NW 23RD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-1803
Country	:	US
Telephone Number	:	405-949-0123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2008
Last Update Date	:	06/26/2008

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