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General NPI Number Information
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NPI Number | 1316539299
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Entity Type | Individual
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Provider Name | BLAKE ALEXANDER CROSBY DMD
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Gender | Male
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Dates
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Enumeration Date | 02/11/2021
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Last Update Date | 07/16/2024
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Provider Practice Location Address
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Address Line | 320 AVENUE K SE STE 1
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City | WINTER HAVEN
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State | FL
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Zip | 33880-4148
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Country | US
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Telephone | 863-293-5099
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Fax |
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Provider Business Mailing Address
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Address Line | 7029 BENTRIDGE DR
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City | LAKELAND
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State | FL
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Zip | 33813-4008
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Country | US
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Telephone | 863-393-5167
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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 | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN26120
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License Number State | FL
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