MEDICARE: DR. RICHARD WAYNE BLAKE DDS PA

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	1223P0221X	Pediatric Dentistry	0005634	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912921867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD WAYNE BLAKE DDS PA

Provider Business Mailing Address
First Line	:	2701 PARK DR
Second Line	:	SUITE #1
City	:	CLEARWATER
State	:	FL
Zip	:	33763-1021
Country	:	US
Telephone Number	:	727-796-2187
Fax Number	:	727-791-7660

Provider Business Practice Location Address
First Line	:	2701 PARK DR
Second Line	:	SUITE #1
City	:	CLEARWATER
State	:	FL
Zip	:	33763-1021
Country	:	US
Telephone Number	:	727-796-2187
Fax Number	:	727-791-7660

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/09/2007

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