1972779916 NPI number — SCOTT M. BLAKE, DDS, PC

Table of content: (NPI 1972779916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972779916 NPI number — SCOTT M. BLAKE, DDS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTT M. BLAKE, DDS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972779916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 S WOODRUFF AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83401-4322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-523-2160
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 S WOODRUFF AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-4322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-2160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
Authorized Official Title or Position:
RECEPTIONIST
Authorized Official Telephone Number:
208-523-2160

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  D3728 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1504752 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 806657300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806720800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118557800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010143970 . This is a "REGENCE BLUESHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6I468 . This is a "FEDERAL BXBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6M014 . This is a "UPIN BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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