Organization
BLAKE DENTISTRY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHANE CHRISTOPHER BLAKE D.M.D. (PRESIDENT)
(814) 274-7262
Entity
Organization
Contact information
Practice address
507 DWIGHT ST, COUDERSPORT, PA 16915-1792
(814) 274-7262
(814) 274-0879
Mailing address
507 DWIGHT ST, COUDERSPORT, PA 16915-1792
(814) 274-7262
(814) 274-0879
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DS-035521
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0019285420002
—
PA
Enumeration date
12/24/2006
Last updated
08/22/2020
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