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General NPI Number Information
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NPI Number | 1346940541
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Entity Type | Individual
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Provider Name | WALLIS BLAKE HARVEY DDS
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Gender | Male
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Dates
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Enumeration Date | 03/06/2023
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Last Update Date | 02/14/2025
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Provider Practice Location Address
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Address Line | 3801 CROSS PARK DR
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City | BRYAN
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State | TX
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Zip | 77802-4140
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Country | US
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Telephone | 979-776-4450
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Fax |
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Provider Business Mailing Address
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Address Line | 406 FOSTER ST
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City | TOMBALL
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State | TX
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Zip | 77375-4825
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Country | US
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Telephone | 361-215-2610
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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 | 39507
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License Number State | TX
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