Healthcare Provider Details

I. General information

NPI: 1578756482
Provider Name (Legal Business Name): BLAKE CHARLES STUART D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RUNION DENTAL CLINIC 2240 WINROW RD
FORT HUACHUCA AZ
85613
US

IV. Provider business mailing address

BUDGE DENTAL CLINIC 3145 GARDEN AVE STE 1278
FORT SAM HOUSTON TX
78234
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-9200
  • Fax:
Mailing address:
  • Phone: 210-808-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6697176-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6697176-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: