MEDICARE: DR. ROBERT A BLAKE D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14749	MA

General Provider Information

NPI Number	:	1356442446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT A BLAKE D.D.S.

Provider Business Mailing Address
First Line	:	3 LANTHORN LN
Second Line	:
City	:	BEVERLY
State	:	MA
Zip	:	01915-4721
Country	:	US
Telephone Number	:	978-927-7686
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 WEST ST
Second Line	:
City	:	BEVERLY
State	:	MA
Zip	:	01915-2228
Country	:	US
Telephone Number	:	978-927-3515
Fax Number	:	978-927-7686

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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