Healthcare Provider Details

I. General information

NPI: 1235188012
Provider Name (Legal Business Name): BLAKE CHANDLER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7409 ALCOA RD STE 5
BRYANT AR
72022-6216
US

IV. Provider business mailing address

4004 STONEYBROOK DR
BRYANT AR
72022-8300
US

V. Phone/Fax

Practice location:
  • Phone: 602-430-0106
  • Fax:
Mailing address:
  • Phone: 602-430-0106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4002
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30776
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: