Provider Demographics
NPI:1972779916
Name:SCOTT M. BLAKE, DDS, PC
Entity Type:Organization
Organization Name:SCOTT M. BLAKE, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-2160
Mailing Address - Street 1:333 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4322
Mailing Address - Country:US
Mailing Address - Phone:208-523-2160
Mailing Address - Fax:
Practice Address - Street 1:333 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4322
Practice Address - Country:US
Practice Address - Phone:208-523-2160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1504752OtherUNITED CONCORDIA
ID806657300Medicaid
ID806720800Medicaid
WY118557800Medicaid
000010143970OtherREGENCE BLUESHIELD
6I468OtherFEDERAL BXBS
6M014OtherUPIN BLUE CROSS