1679089239 NPI number — BLAINE D. AUSTIN DDS INC.

Table of content: (NPI 1679089239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679089239 NPI number — BLAINE D. AUSTIN DDS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLAINE D. AUSTIN DDS INC.
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:
6
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:
1679089239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 E 3900 S STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84124-1367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-265-1500
Provider Business Mailing Address Fax Number:
801-259-9963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 EAST 3900 SOUTH
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-264-1500
Provider Business Practice Location Address Fax Number:
801-265-9963
Provider Enumeration Date:
12/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
AUSTIN
Authorized Official First Name:
BLAINE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ORAL MAXILLO-FACIAL SURGERY
Authorized Official Telephone Number:
801-759-4378

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  140958 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: U000005310 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com