Healthcare Provider Details

I. General information

NPI: 1255993283
Provider Name (Legal Business Name): BLAKE D COLLING DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2019
Last Update Date: 08/04/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CT
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

200 MERCY CT DENTAL DEPARTMENT
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-719-4747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number103900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: