Provider Demographics
NPI:1316147721
Name:HORN-BLAKE, MISTY RENE' (DDS)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:RENE'
Last Name:HORN-BLAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SUNSET DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7906
Mailing Address - Country:US
Mailing Address - Phone:423-283-8830
Mailing Address - Fax:
Practice Address - Street 1:1301 SUNSET DR
Practice Address - Street 2:SUITE 6
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7906
Practice Address - Country:US
Practice Address - Phone:423-283-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8728122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist