Provider Demographics
NPI:1568786655
Name:MOLDENHAUER, BLAIR DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:DAVID
Last Name:MOLDENHAUER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:238 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-2908
Mailing Address - Country:US
Mailing Address - Phone:608-318-2119
Mailing Address - Fax:608-318-2119
Practice Address - Street 1:238 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2908
Practice Address - Country:US
Practice Address - Phone:608-318-2119
Practice Address - Fax:608-318-2119
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33310151223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics