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General NPI Number Information
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NPI Number | 1588831275
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Entity Type | Organization
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Legal Business Name | MISTY HORN-BLAKE D.D.S PC
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Dates
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Enumeration Date | 05/12/2008
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Last Update Date | 05/12/2008
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Provider Practice Location Address
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Address Line | 1301 SUNSET DR SUITE 6
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City | JOHNSON CITY
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State | TN
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Zip | 37604-7906
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Country | US
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Telephone | 423-283-8830
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Fax | 423-283-8820
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Provider Business Mailing Address
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Address Line | 1301 SUNSET DR SUITE 6
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City | JOHNSON CITY
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State | TN
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Zip | 37604-7906
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Country | US
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Telephone | 423-283-8830
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Fax | 423-283-8820
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | MRS. MISTY R HORN-BLAKE
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Credential | D.D.S
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Telephone | 423-283-8830
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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 | 8728
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License Number State | TN
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