Provider Demographics
NPI:1073654299
Name:LOSEE, BLAIR I
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:I
Last Name:LOSEE
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 1:1405 MAGIC WAND ST
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7537
Mailing Address - Country:US
Mailing Address - Phone:801-545-0257
Mailing Address - Fax:801-766-5445
Practice Address - Street 1:3098 NORTH EXECUTIVE PKWY
Practice Address - Street 2:SUITE #250
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:801-766-5300
Practice Address - Fax:801-766-5445
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139721-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87-0370312OtherTAX ID #
UT139721-9922OtherSTATE ID #
UT139721-9922OtherSTATE ID #