Provider Demographics
NPI:1376821371
Name:BLANDON, MICHAEL JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:BLANDON
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 1:206 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04742-1121
Mailing Address - Country:US
Mailing Address - Phone:207-473-7723
Mailing Address - Fax:
Practice Address - Street 1:206 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04742-1121
Practice Address - Country:US
Practice Address - Phone:207-473-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDENT4199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist