Provider Demographics
NPI:1790837839
Name:ODONNELL, BLYTHE A (DDS)
Entity Type:Individual
Prefix:MRS
First Name:BLYTHE
Middle Name:A
Last Name:ODONNELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 CYPRESS STREET
Mailing Address - Street 2:
Mailing Address - City:MANISTIE
Mailing Address - State:MI
Mailing Address - Zip Code:49660
Mailing Address - Country:US
Mailing Address - Phone:231-723-6512
Mailing Address - Fax:231-723-0000
Practice Address - Street 1:812 CYPRESS STREET
Practice Address - Street 2:
Practice Address - City:MANISTIE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-723-6512
Practice Address - Fax:231-723-0000
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist