Blake Dentistry, PC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DS-035521 Issued in PA

Legal business name

BLAKE DENTISTRY, PC

Practice address

507 Dwight St
Coudersport, PA 16915-1792

Phone

(814) 274-7262

Fax

(814) 274-0879

NPI assigned

Dec 24, 2006

Organization subpart

No

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

Authorized official

Name

Dr. Shane Christopher Blake, D.M.D.NPI 1023360609

Title

President

Phone

(814) 274-7262

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Shane Christopher Blake, D.M.D.

  • Dentist
  • Coudersport, PA
  • NPI 1023360609
  NPD (past) Authorized official

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

{
    "created_epoch": "1166918400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1962567644",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "507 DWIGHT ST",
            "city": "COUDERSPORT",
            "state": "PA",
            "postal_code": "169151792",
            "telephone_number": "814-274-7262",
            "fax_number": "814-274-0879"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "507 DWIGHT ST",
            "city": "COUDERSPORT",
            "state": "PA",
            "postal_code": "169151792",
            "telephone_number": "814-274-7262",
            "fax_number": "814-274-0879"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLAKE DENTISTRY, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-24",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BLAKE",
        "authorized_official_first_name": "SHANE",
        "authorized_official_middle_name": "CHRISTOPHER",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "814-274-7262",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "PA",
            "license": "DS-035521",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0019285420002",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kristine N Ball, CNM
• Trisha Marie Bauer, COTA/L
• Adriane Elizabeth Biancuzzo, PTA
• Shayla Bickel
• Stephanie Black, ATC
• Shane Christopher Blake, D.M.D.
• Leah M Blendinger, COTA/L
• Ashley Lynn Booterbaugh, MA CF-SLP
• Mary Kay Bowersox
• David Charles Brown III, PA-C

• General Practice Dentistry in Coudersport, PA
• Providers in Coudersport, PA by specialty
• General Practice Dentistry in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.