MEDICARE: DR. THOMAS JOEL BLAKE D.D.S., M.S.D.

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	DE00010588	WA
2	1223G0001X	General Practice Dentistry	5226914-9921	UT
3	1223G0001X	General Practice Dentistry	5775	AZ

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

General Provider Information

NPI Number	:	1992862593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS JOEL BLAKE D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	721 N PINES RD
Second Line	:	SUITE 101
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-5225
Country	:	US
Telephone Number	:	509-926-1234
Fax Number	:	509-926-1701

Provider Business Practice Location Address
First Line	:	721 N PINES RD
Second Line	:	SUITE 101
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-5225
Country	:	US
Telephone Number	:	509-926-1234
Fax Number	:	509-926-1701

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	08/30/2012

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