Provider Demographics
NPI:1881853208
Name:LYNN R. BLAISDELL, DDS, PA
Entity Type:Organization
Organization Name:LYNN R. BLAISDELL, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLAISDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-377-9696
Mailing Address - Street 1:8877 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1671
Mailing Address - Country:US
Mailing Address - Phone:208-377-9696
Mailing Address - Fax:208-377-9698
Practice Address - Street 1:8877 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1671
Practice Address - Country:US
Practice Address - Phone:208-377-9696
Practice Address - Fax:208-377-9698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD16971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty