Healthcare Provider Details

I. General information

NPI: 1972234193
Provider Name (Legal Business Name): BLAKE MONTGOMERY HUTZLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 LEGACY DR
FRISCO TX
75034-0816
US

IV. Provider business mailing address

3700 GWINN CT
PLANO TX
75025-2083
US

V. Phone/Fax

Practice location:
  • Phone: 972-335-9313
  • Fax:
Mailing address:
  • Phone: 214-534-8773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38630
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: