MEDICARE: DR. BLAKE ISAACSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7002323-9922	UT

General Provider Information

NPI Number	:	1184039505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE ISAACSON DDS

Provider Business Mailing Address
First Line	:	2674 S 1800 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4016
Country	:	US
Telephone Number	:	801-822-9756
Fax Number	:

Provider Business Practice Location Address
First Line	:	2674 S 1800 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4016
Country	:	US
Telephone Number	:	801-822-9756
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2014
Last Update Date	:	06/24/2014

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