Basic Information
| Provider Information | |||||||||
| NPI: | 1619585833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | AHREN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1948 BRAGET ST | ||||||||
| Address2: | |||||||||
| City: | DUPONT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983279796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5636130907 | ||||||||
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| Practice Location | |||||||||
| Address1: | US ARMY DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | BUILDING 9900 LINCOLN STREET, SECOND FLOOR | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684079 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DDS-09756 | IA | Y | Dental Providers | Dentist | General Practice |
No ID Information.