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General NPI Number Information
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NPI Number | 1407864440
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Entity Type | Individual
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Provider Name | ROBERT EDWARD BLAKE D.D.S.,M.S.
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Gender | Male
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 104 N PARK DR
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1645
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Country | US
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Telephone | 770-461-9931
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Fax | 770-461-9176
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Provider Business Mailing Address
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Address Line | 104 N PARK DR
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1645
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Country | US
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Telephone | 770-461-9931
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Fax | 770-461-9176
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 7991
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License Number State | GA
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