Provider Demographics
NPI:1942406715
Name:BLAISDELL, CRAIG D (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:D
Last Name:BLAISDELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 W ASHBY DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5696
Mailing Address - Country:US
Mailing Address - Phone:208-888-1677
Mailing Address - Fax:
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
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD40701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice