Provider Demographics
NPI:1033190251
Name:BLUE, MARK STEPHEN
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:BLUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S. CAMINO DEL RIO
Mailing Address - Street 2:B1
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-4244
Mailing Address - Country:US
Mailing Address - Phone:970-385-6800
Mailing Address - Fax:970-385-4620
Practice Address - Street 1:555 S. CAMINO DEL RIO
Practice Address - Street 2:B1
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303
Practice Address - Country:US
Practice Address - Phone:970-385-6800
Practice Address - Fax:970-385-4620
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO83841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics