Healthcare Provider Details

I. General information

NPI: 1891288775
Provider Name (Legal Business Name): DR. BLAKE WUTHNOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 E IRON AVE
SALINA KS
67401-3237
US

IV. Provider business mailing address

1615 E IRON AVE
SALINA KS
67401-3237
US

V. Phone/Fax

Practice location:
  • Phone: 785-823-5568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61405
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: