Provider Demographics
NPI:1912921867
Name:BLAKE, RICHARD WAYNE (DDS PA)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 PARK DR
Mailing Address - Street 2:SUITE #1
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-1021
Mailing Address - Country:US
Mailing Address - Phone:727-796-2187
Mailing Address - Fax:727-791-7660
Practice Address - Street 1:2701 PARK DR
Practice Address - Street 2:SUITE #1
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1021
Practice Address - Country:US
Practice Address - Phone:727-796-2187
Practice Address - Fax:727-791-7660
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00056341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074223600Medicaid