1992862593 NPI number — DR. THOMAS JOEL BLAKE D.D.S., M.S.D.

Table of content: (NPI 1558346767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992862593 NPI number — DR. THOMAS JOEL BLAKE D.D.S., M.S.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
THOMAS
Provider Middle Name:
JOEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S., M.S.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992862593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 N PINES RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99206-5225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-926-1234
Provider Business Mailing Address Fax Number:
509-926-1701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 N PINES RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99206-5225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-926-1234
Provider Business Practice Location Address Fax Number:
509-926-1701
Provider Enumeration Date:
01/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DE00010588 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5226914-9921 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 5775 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5051255 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".