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General NPI Number Information
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NPI Number | 1770993180
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Entity Type | Organization
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Legal Business Name | BLAKE M. BULLARD, D.D.S., P.L.L.C.
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Dates
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Enumeration Date | 05/07/2014
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Last Update Date | 07/06/2018
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Provider Practice Location Address
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Address Line | 5008 W. UNIVERSITY BLVD.
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City | DURANT
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State | OK
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Zip | 74701-2978
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Country | US
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Telephone | 580-931-3366
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Fax | 580-931-3390
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Provider Business Mailing Address
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Address Line | 5008 W. UNIVERSITY BLVD.
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City | DURANT
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State | OK
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Zip | 74701-2978
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Country | US
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Telephone | 580-931-3366
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Fax | 580-931-3390
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Authorized Official
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Title or Position | OWNER
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Name | BLAKE MICHAEL BULLARD
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Credential | D.D.S.
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Telephone | 580-931-3366
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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 | 6022
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License Number State | OK
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