Provider Demographics
NPI:1003804303
Name:BLOXSON, MICHELE LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:BLOXSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-562-4461
Mailing Address - Fax:719-584-7694
Practice Address - Street 1:4257 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-1406
Practice Address - Country:US
Practice Address - Phone:937-268-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010189691223S0112X
OH30-0227141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1635834OtherUNITED CONCORDIA
88123MIOtherBAYSIDE
D801095OtherBLUE CROSS
88096MIOtherWADSWORTH
88170MIOtherOUTER DRIVE
88171MIOtherCOMMERCE
381908328020OtherDENTAL BLUE
MI4667047Medicaid