Provider Demographics
NPI:1790805562
Name:BLAIR, MARK A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
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 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:1-D
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-458-0172
Mailing Address - Fax:502-458-4621
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:1-D
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-458-0172
Practice Address - Fax:502-458-4621
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice