Provider Demographics
NPI:1295021632
Name:HAMMOND, BLAINE A (DMD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:A
Last Name:HAMMOND
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 1:640 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5299
Mailing Address - Country:US
Mailing Address - Phone:208-523-5400
Mailing Address - Fax:208-528-0565
Practice Address - Street 1:640 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5299
Practice Address - Country:US
Practice Address - Phone:208-523-5400
Practice Address - Fax:208-528-0565
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD43691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice