Provider Demographics
NPI:1306295308
Name:FERANDO, BLAKE (DMD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:FERANDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 FORT ZUMWALT SQ
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3065
Mailing Address - Country:US
Mailing Address - Phone:636-978-6400
Mailing Address - Fax:
Practice Address - Street 1:346 FORT ZUMWALT SQ
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3065
Practice Address - Country:US
Practice Address - Phone:636-978-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist