Healthcare Provider Details

I. General information

NPI: 1508450685
Provider Name (Legal Business Name): HEATHER DANELLE BLAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 S 12TH ST
ROCKY FORD CO
81067-2127
US

IV. Provider business mailing address

903 S 12TH ST
ROCKY FORD CO
81067-2127
US

V. Phone/Fax

Practice location:
  • Phone: 719-254-7623
  • Fax:
Mailing address:
  • Phone: 719-254-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number905876
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: