Provider Demographics
NPI:1164557484
Name:BLOSSFELD, CAROL M (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:M
Last Name:BLOSSFELD
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 1:3201 E MEMORIAL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7104
Mailing Address - Country:US
Mailing Address - Phone:405-475-9221
Mailing Address - Fax:405-475-9224
Practice Address - Street 1:3201 E MEMORIAL RD
Practice Address - Street 2:SUITE A
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-7104
Practice Address - Country:US
Practice Address - Phone:405-475-9221
Practice Address - Fax:405-475-9224
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice