Provider Demographics
NPI:1396290243
Name:BLAIR, JESSE (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:BLAIR
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 1:2121 E DUPONT RD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1546
Mailing Address - Country:US
Mailing Address - Phone:260-490-9684
Mailing Address - Fax:
Practice Address - Street 1:2121 E DUPONT RD STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1546
Practice Address - Country:US
Practice Address - Phone:843-281-0182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013093A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice