Healthcare Provider Details

I. General information

NPI: 1124199807
Provider Name (Legal Business Name): BLAKE R. HENRY D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7705 E 81ST ST
TULSA OK
74133-4200
US

IV. Provider business mailing address

7705 E 81ST ST
TULSA OK
74133-4200
US

V. Phone/Fax

Practice location:
  • Phone: 918-294-7705
  • Fax:
Mailing address:
  • Phone: 918-294-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberORTHODONTIST #152
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: