Provider Demographics
NPI:1255846754
Name:BLYTHE A O'DONNELL, PLLC
Entity type:Organization
Organization Name:BLYTHE A O'DONNELL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BLYTHE
Authorized Official - Middle Name:A
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-723-6512
Mailing Address - Street 1:812 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2110
Mailing Address - Country:US
Mailing Address - Phone:231-723-6512
Mailing Address - Fax:231-723-0000
Practice Address - Street 1:812 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-2110
Practice Address - Country:US
Practice Address - Phone:231-723-6512
Practice Address - Fax:231-723-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11462261QD0000X
MI18268261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental