Provider Demographics
NPI:1144338963
Name:BLAKEMAN, H. DWAINE (DMD)
Entity type:Individual
Prefix:DR
First Name:H.
Middle Name:DWAINE
Last Name:BLAKEMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 SCHERM RD
Mailing Address - Street 2:DENTAL ARTS BUILDING
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6022
Mailing Address - Country:US
Mailing Address - Phone:270-926-9907
Mailing Address - Fax:270-926-7801
Practice Address - Street 1:1208 EAST BYERS AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7558
Practice Address - Country:US
Practice Address - Phone:270-926-3838
Practice Address - Fax:270-926-0452
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60043122Medicaid