Provider Demographics
NPI:1669446258
Name:AUSTIN, BLAINE DONALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:DONALD
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5742 S 1475 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4855
Mailing Address - Country:US
Mailing Address - Phone:801-399-3701
Mailing Address - Fax:801-399-3702
Practice Address - Street 1:5742 S 1475 E
Practice Address - Street 2:SUITE 100
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-399-3701
Practice Address - Fax:801-399-3702
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1409581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT77993Medicare UPIN
UT000005214Medicare ID - Type Unspecified