Healthcare Provider Details

I. General information

NPI: 1417077918
Provider Name (Legal Business Name): BLAINE RODNEY COUSER DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 E BASELINE RD SUITE # 104
MESA AZ
85206-4613
US

IV. Provider business mailing address

4540 E BASELINE RD SUITE # 104
MESA AZ
85206-4613
US

V. Phone/Fax

Practice location:
  • Phone: 480-813-2222
  • Fax: 480-907-7619
Mailing address:
  • Phone: 480-813-2222
  • Fax: 480-907-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6257
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: