Provider Demographics
NPI:1720416290
Name:JEFFREY P BLAIR, DDS, PC
Entity Type:Organization
Organization Name:JEFFREY P BLAIR, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:P
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-741-1400
Mailing Address - Street 1:12205 GAYTON RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-3212
Mailing Address - Country:US
Mailing Address - Phone:804-741-1400
Mailing Address - Fax:804-741-7700
Practice Address - Street 1:12205 GAYTON RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-3212
Practice Address - Country:US
Practice Address - Phone:804-741-1400
Practice Address - Fax:804-741-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-21
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178644Medicaid