Provider Demographics
NPI:1720095599
Name:BLAKE, DENNIS N (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:N
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PIGGOTT
Mailing Address - State:AR
Mailing Address - Zip Code:72454-1538
Mailing Address - Country:US
Mailing Address - Phone:870-598-2236
Mailing Address - Fax:870-598-3080
Practice Address - Street 1:425 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PIGGOTT
Practice Address - State:AR
Practice Address - Zip Code:72454-1538
Practice Address - Country:US
Practice Address - Phone:870-598-2236
Practice Address - Fax:870-598-3080
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141033001Medicaid
MO205038201Medicaid
MO205038201Medicaid
AR141033001Medicaid
ARBB6540531OtherDEA