# BLAKE DENTISTRY, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1962567644
- **Authorized official:** DR. SHANE CHRISTOPHER BLAKE D.M.D. (PRESIDENT)
- **Authorized official phone:** (814) 274-7262

## Contact information

- **Practice address:** 507 DWIGHT ST, COUDERSPORT, PA 16915-1792
- **Practice address phone:** (814) 274-7262
- **Practice address fax:** (814) 274-0879
- **Mailing address:** 507 DWIGHT ST, COUDERSPORT, PA 16915-1792
- **Mailing address phone:** (814) 274-7262
- **Mailing address fax:** (814) 274-0879

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DS-035521 | PA | Yes |

## Other

- **Enumeration date:** 12/24/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0019285420002 | — | PA |