Healthcare Provider Details

I. General information

NPI: 1639004351
Provider Name (Legal Business Name): BLAKE AN HAN TONG PALLISER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W MAIN ST
CARY IL
60013-2058
US

IV. Provider business mailing address

700 W MAIN ST
CARY IL
60013-2058
US

V. Phone/Fax

Practice location:
  • Phone: 847-639-3031
  • Fax: 847-639-3084
Mailing address:
  • Phone: 847-639-3031
  • Fax: 847-639-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037190
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: