Provider Demographics
NPI:1659546174
Name:BLAIR, RANDALL PARLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:PARLEY
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:37 W ARCHERFIELD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6587
Mailing Address - Country:US
Mailing Address - Phone:208-938-9958
Mailing Address - Fax:208-298-0646
Practice Address - Street 1:37 W ARCHERFIELD ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6587
Practice Address - Country:US
Practice Address - Phone:208-938-9958
Practice Address - Fax:208-298-0646
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4550PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry