Provider Demographics
NPI:1134281512
Name:BLAICH, GEORGE F IV (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:F
Last Name:BLAICH
Suffix:IV
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:BLAICH
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1300 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3314
Mailing Address - Country:US
Mailing Address - Phone:573-785-0111
Mailing Address - Fax:
Practice Address - Street 1:1300 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3314
Practice Address - Country:US
Practice Address - Phone:573-785-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO135471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice