Healthcare Provider Details

I. General information

NPI: 1790733079
Provider Name (Legal Business Name): ANN M BLAKE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-2273
  • Fax:
Mailing address:
  • Phone: 702-653-2682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30019252
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30019252
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: