Healthcare Provider Details

I. General information

NPI: 1861841918
Provider Name (Legal Business Name): RYAN BLAKE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 N PINES RD STE 101
SPOKANE VALLEY WA
99206-5225
US

IV. Provider business mailing address

721 N PINES RD STE 101
SPOKANE VALLEY WA
99206-5225
US

V. Phone/Fax

Practice location:
  • Phone: 509-926-1234
  • Fax:
Mailing address:
  • Phone: 435-669-7308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10161
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number60796314
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: