Healthcare Provider Details

I. General information

NPI: 1760166599
Provider Name (Legal Business Name): BLAKE CHRISTOPHER PUTMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 S DURKIN DR STE B
SPRINGFIELD IL
62704-6017
US

IV. Provider business mailing address

832 COVENTRY PT
SPRINGFIELD IL
62702-3389
US

V. Phone/Fax

Practice location:
  • Phone: 217-793-1979
  • Fax:
Mailing address:
  • Phone: 217-691-7848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.036815
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: