Provider Demographics
NPI:1073686663
Name:BLODGETT, KRIS M (DMD)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:M
Last Name:BLODGETT
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:PO BOX 901
Mailing Address - Street 2:354 W ADAMS STREET
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-0901
Mailing Address - Country:US
Mailing Address - Phone:541-549-0973
Mailing Address - Fax:541-549-9542
Practice Address - Street 1:354 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-0901
Practice Address - Country:US
Practice Address - Phone:541-549-0973
Practice Address - Fax:541-549-9542
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD82301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice