Provider Demographics
NPI:1144711896
Name:KOPF, BLAKE (DDS)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:KOPF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54486 852 RD
Mailing Address - Street 2:
Mailing Address - City:PIERCE
Mailing Address - State:NE
Mailing Address - Zip Code:68767-3602
Mailing Address - Country:US
Mailing Address - Phone:402-885-0555
Mailing Address - Fax:
Practice Address - Street 1:11 COURT ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069
Practice Address - Country:US
Practice Address - Phone:605-624-8695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7452122300000X
SDD1188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist