Thomas R Blake, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

7973 Issued in IN

Practice address

2409 Fairoak Dr
Fort Wayne, IN 46809-2301

Phone

(260) 747-5745

NPI assigned

Feb 21, 2007

Last updated

Jul 9, 2007By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• JSBC Services LLC

  • Dental Clinic/Center
  • Fort Wayne, IN
  • NPI 1912886920
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172016000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1669517330",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2409 FAIROAK DR",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468092301",
            "telephone_number": "260-747-5745"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2409 FAIROAK DR",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468092301",
            "telephone_number": "260-747-5745"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLAKE",
        "first_name": "THOMAS",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-02-21",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IN",
            "license": "7973",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "777279",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHP",
            "identifier": "1091",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Natalie Joy Blair, COTA
• Nathaniel Blair, ATC
• Ryan Michael Blair, RBT
• Samantha Blair
• Emily Blake
• Kelly Blakey, MSW, LSW
• Melanie Blanchard
• Theodore Joseph-Douglas Blanford, HIS
• Kelsey R Blankenship, RBT
• Larry Nathaniel Blankenship, AUD

• General Practice Dentistry in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• General Practice Dentistry in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.