Provider Demographics
NPI:1831243013
Name:BLAKE, ALAN MAX
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:MAX
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-1534
Mailing Address - Country:US
Mailing Address - Phone:712-362-5454
Mailing Address - Fax:712-362-4737
Practice Address - Street 1:808 N 9TH ST
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-1534
Practice Address - Country:US
Practice Address - Phone:712-362-5454
Practice Address - Fax:712-362-4737
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA060081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06008OtherSTATE DENTAL LICENSE
IA0052308Medicaid