Provider Demographics
NPI:1881857753
Name:BLAISDELL DENTAL CENTER, PA
Entity Type:Organization
Organization Name:BLAISDELL DENTAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLAISDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-459-2376
Mailing Address - Street 1:1916 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4811
Mailing Address - Country:US
Mailing Address - Phone:208-459-2376
Mailing Address - Fax:208-459-1524
Practice Address - Street 1:1916 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4811
Practice Address - Country:US
Practice Address - Phone:208-459-2376
Practice Address - Fax:208-459-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty