Provider Demographics
NPI:1386783488
Name:DR CHRISTOPHER BLAKE SC
Entity type:Organization
Organization Name:DR CHRISTOPHER BLAKE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT OF SERVICE CORPOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-789-9200
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4336
Mailing Address - Country:US
Mailing Address - Phone:262-789-9200
Mailing Address - Fax:262-789-9213
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4336
Practice Address - Country:US
Practice Address - Phone:262-789-9200
Practice Address - Fax:262-789-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002097015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty