Most Relevant Information
Provider Data
| NPI Number: | 1003485624 |
| Provider Name: | TERRY MICHAEL BLAKE DDS, MSD |
| Entity Type: | Individual |
| Taxonomy Code: | 1223X0400X |
| Specialty: | Dentist |
| License Number: | 011574 |
Most Important Dates
| Enumeration Date: | 06/18/2021 |
| Last Updated: | 06/18/2021 |
Provider Practice Location
225 SOUTH MAIN
SUITE 101
O'FALLON
MO
63366
Practice Location Phone/Fax
| Phone: | 6362726666 |
| Fax: | 6362726661 |
Provider Mailing Location
225 SOUTH MAIN
SUITE 101
O'FALLON
MO
63366
Provider Mailing Phone/Fax
| Phone: | 6362726666 |
| Fax: | 6362726661 |