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General NPI Number Information
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NPI Number | 1295353480
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Entity Type | Individual
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Provider Name | BLAKE CHRISTOPHER ROBERTS DDS
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Gender | Male
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Dates
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Enumeration Date | 07/14/2020
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Last Update Date | 07/14/2020
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Provider Practice Location Address
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Address Line | 1112 BAXTER ST
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City | NEOSHO
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State | MO
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Zip | 64850-7814
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Country | US
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Telephone | 417-451-2403
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Fax |
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Provider Business Mailing Address
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Address Line | 1551 HALE MCGINTY DR
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City | NEOSHO
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State | MO
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Zip | 64850-7814
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Country | US
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Telephone | 417-434-1203
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2020021104
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License Number State | MO
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