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General NPI Number Information
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NPI Number | 1629517719
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Entity Type | Individual
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Provider Name | BLAKE LEWIS TOLLISON DMD, MSD
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Gender | Male
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Dates
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Enumeration Date | 02/22/2017
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 20 CREEKVIEW CT STE A
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City | GREENVILLE
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State | SC
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Zip | 29615-4800
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Country | US
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Telephone | 864-329-1971
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Fax | 864-329-1973
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Provider Business Mailing Address
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Address Line | 20 CREEKVIEW CT STE A
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City | GREENVILLE
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State | SC
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Zip | 29615-4800
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Country | US
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Telephone | 864-329-1971
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Fax | 864-329-1973
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D.6883-C1
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8950
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 10920
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License Number State | SC
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