MEDICARE: DR. BLAKE LATENDRESSE 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	1223G0001X	General Practice Dentistry	7846	NE

General Provider Information

NPI Number	:	1285369157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE LATENDRESSE DDS

Provider Business Mailing Address
First Line	:	6462 POPPLETON AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68106-1542
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 LINCOLN RD STE 100
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-2341
Country	:	US
Telephone Number	:	402-293-1176
Fax Number	:

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

Provider Enumeration Date	:	07/23/2022
Last Update Date	:	07/23/2022

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Directions to “ DR. BLAKE LATENDRESSE DDS” Practice Location

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