Provider Demographics
NPI:1578958252
Name:BLACKFOOT FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:BLACKFOOT FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CADE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-785-6833
Mailing Address - Street 1:380 W JUDICIAL ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2122
Mailing Address - Country:US
Mailing Address - Phone:208-785-6833
Mailing Address - Fax:208-785-5362
Practice Address - Street 1:380 W JUDICIAL ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2122
Practice Address - Country:US
Practice Address - Phone:208-785-6833
Practice Address - Fax:208-785-5362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty