Provider Demographics
NPI:1619191251
Name:GARY BLAICH D.D.S., P.A.
Entity Type:Organization
Organization Name:GARY BLAICH D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-251-0604
Mailing Address - Street 1:1509 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3307
Mailing Address - Country:US
Mailing Address - Phone:620-251-0606
Mailing Address - Fax:
Practice Address - Street 1:1509 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3307
Practice Address - Country:US
Practice Address - Phone:620-251-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6743305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization