MEDICARE: DR. THOMAS R BLAKE DDS

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	7973	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	777279	OTHER	IN	UNITED CONCORDIA
2	1091	OTHER	IN	PHP

General Provider Information

NPI Number	:	1669517330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS R BLAKE DDS

Provider Business Mailing Address
First Line	:	2409 FAIROAK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46809-2301
Country	:	US
Telephone Number	:	260-747-5745
Fax Number	:

Provider Business Practice Location Address
First Line	:	2409 FAIROAK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46809-2301
Country	:	US
Telephone Number	:	260-747-5745
Fax Number	:

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/09/2007

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