Provider Demographics
NPI:1316704208
Name:SAMPER, BLAKE TYLER (DDS)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:TYLER
Last Name:SAMPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11815 VANCE JACKSON RD APT 2401
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1445
Mailing Address - Country:US
Mailing Address - Phone:205-746-7318
Mailing Address - Fax:
Practice Address - Street 1:5540 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9262
Practice Address - Country:US
Practice Address - Phone:803-358-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.108061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice