Terry Michael Blake, DDS, MSD
Individual provider Active NPI Orthodontics and Dentofacial Orthopedics Dentistry · O'Fallon, MO
NPI 1003485624 · NPPES record last updated Jun 18, 2021
Key facts
- NPI
- 1003485624
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry 1223X0400X
- License
- 011574 (MO)
- Practice address
- 225 South Main
Suite 101
O'Fallon, MO 63366 - Phone
- (636) 272-6666
- Fax
- (636) 272-6661
- NPI assigned
- Jun 18, 2021
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 011574 | MO | MD | Orthodontics and Dentofacial Orthopedic Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | 011574 | MO | Yes |
Addresses
Primary practice location
225 South Main
Suite 101
O'Fallon, MO 63366
Mailing address
225 South Main
Suite 101
O'Fallon, MO 63366
Phone (636) 272-6666
Other providers in O'Fallon, MO
- Tara Lynn Barnes-Cherry
- Matthew A Beckerdite
- Danielle R Berra
- Sarah Biondo
- Sara Birkemeier
- Jacob Scott Bleyer
- Michael Kenneth Brown
- Jill Buery
- Marianna Burkemper
- Bess M Cain
All providers in O'Fallon, MO · Orthodontics and Dentofacial Orthopedics Dentistry in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 18, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.