Provider Demographics
NPI:1750376968
Name:EDINGER, BLAKE J (DDS)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:J
Last Name:EDINGER
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 1:15954 RIVERS EDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7894
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:715-634-2541
Practice Address - Street 1:15397 STATE HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138
Practice Address - Country:US
Practice Address - Phone:715-276-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100065650Medicaid