Provider Demographics
NPI:1629483987
Name:BLAIR PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:BLAIR PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-485-9804
Mailing Address - Street 1:5360 N EAGLE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-4901
Mailing Address - Country:US
Mailing Address - Phone:208-938-9958
Mailing Address - Fax:
Practice Address - Street 1:5360 N EAGLE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-4901
Practice Address - Country:US
Practice Address - Phone:208-938-9958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4550PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty