Provider Demographics
NPI:1619332764
Name:BLAKE G. SINCLAIR, DDS II, P.A.
Entity type:Organization
Organization Name:BLAKE G. SINCLAIR, DDS II, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-560-2275
Mailing Address - Street 1:3801 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2473
Mailing Address - Country:US
Mailing Address - Phone:936-560-2275
Mailing Address - Fax:936-560-2270
Practice Address - Street 1:3801 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2473
Practice Address - Country:US
Practice Address - Phone:936-560-2275
Practice Address - Fax:936-560-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17163122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty