Organization
RICHARD W BLAKE DDS PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RICHARD WAYNE BLAKE DDS (OWNER/PRESIDENT)
19047432000
Entity
Organization
Contact information
Practice address
943 CESERY BLVD STE D, JACKSONVILLE, FL 32211-5655
(904) 743-2000
(904) 744-0598
Mailing address
943 CESERY BLVD STE D, JACKSONVILLE, FL 32211-5655
(904) 743-2000
(904) 744-0598
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
0005634
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
074223600
—
FL
Enumeration date
06/27/2013
Last updated
06/27/2013
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