Healthcare Provider Details

I. General information

NPI: 1255138251
Provider Name (Legal Business Name): CHRISTOPHER SHAWN BLAKE D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15613 GENERAL PULLER HWY
DELTAVILLE VA
23043-2372
US

IV. Provider business mailing address

15613 GENERAL PULLER HWY
DELTAVILLE VA
23043-2372
US

V. Phone/Fax

Practice location:
  • Phone: 804-455-8263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419912
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: