Provider Demographics
NPI:1417077918
Name:COUSER, BLAINE RODNEY (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:RODNEY
Last Name:COUSER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 E BASELINE RD
Mailing Address - Street 2:SUITE # 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4613
Mailing Address - Country:US
Mailing Address - Phone:480-813-2222
Mailing Address - Fax:480-907-7619
Practice Address - Street 1:4540 E BASELINE RD
Practice Address - Street 2:SUITE # 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4613
Practice Address - Country:US
Practice Address - Phone:480-813-2222
Practice Address - Fax:480-907-7619
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ963943OtherAHCCCS PROGRAM NUMBER