Provider Demographics
NPI:1184958159
Name:MARK H. BLAISDELL DDS, PC
Entity type:Organization
Organization Name:MARK H. BLAISDELL DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:BLAISDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-292-6819
Mailing Address - Street 1:625 E 500 S
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-3882
Mailing Address - Country:US
Mailing Address - Phone:801-292-6819
Mailing Address - Fax:801-298-8573
Practice Address - Street 1:625 E 500 S
Practice Address - Street 2:SUITE 203
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-3882
Practice Address - Country:US
Practice Address - Phone:801-292-6819
Practice Address - Fax:801-298-8573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2009-37520122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty