Provider Demographics
NPI:1730133125
Name:BLAIR, JEFFREY COLIN (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:COLIN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2354
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-2354
Mailing Address - Country:US
Mailing Address - Phone:928-634-7312
Mailing Address - Fax:
Practice Address - Street 1:1380 DUNCAN DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-5539
Practice Address - Country:US
Practice Address - Phone:928-634-8567
Practice Address - Fax:928-634-8646
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist