Provider Demographics
NPI:1376684175
Name:BLAKE, SCOTT M (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4322
Mailing Address - Country:US
Mailing Address - Phone:208-523-2160
Mailing Address - Fax:208-552-8079
Practice Address - Street 1:333 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4322
Practice Address - Country:US
Practice Address - Phone:208-523-2160
Practice Address - Fax:208-552-8079
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37281223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010143970OtherREGENCE BLUE SHIELD
WY118557800Medicaid
ID1504752OtherUNITED CONCORDIA
ID6I468OtherFEDERAL BLUE CROSS
ID806657300Medicaid
ID806720800Medicaid
ID6M014Medicare UPIN