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General NPI Number Information
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NPI Number | 1912921867
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Entity Type | Individual
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Provider Name | RICHARD WAYNE BLAKE DDS PA
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Gender | Male
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 2701 PARK DR SUITE #1
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City | CLEARWATER
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State | FL
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Zip | 33763-1021
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Country | US
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Telephone | 727-796-2187
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Fax | 727-791-7660
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Provider Business Mailing Address
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Address Line | 2701 PARK DR SUITE #1
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City | CLEARWATER
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State | FL
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Zip | 33763-1021
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Country | US
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Telephone | 727-796-2187
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Fax | 727-791-7660
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0005634
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License Number State | FL
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