Provider Demographics
NPI:1285040394
Name:IMAM, BLAKE (DMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:IMAM
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 1:317 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1608
Mailing Address - Country:US
Mailing Address - Phone:208-888-2055
Mailing Address - Fax:208-395-1017
Practice Address - Street 1:317 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1608
Practice Address - Country:US
Practice Address - Phone:208-888-2055
Practice Address - Fax:208-395-1017
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist