Healthcare Provider Details

I. General information

NPI: 1407864440
Provider Name (Legal Business Name): ROBERT EDWARD BLAKE D.D.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 N PARK DR
FAYETTEVILLE GA
30214-1645
US

IV. Provider business mailing address

104 N PARK DR
FAYETTEVILLE GA
30214-1645
US

V. Phone/Fax

Practice location:
  • Phone: 770-461-9931
  • Fax: 770-461-9176
Mailing address:
  • Phone: 770-461-9931
  • Fax: 770-461-9176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7991
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: