Healthcare Provider Details

I. General information

NPI: 1376684175
Provider Name (Legal Business Name): SCOTT M BLAKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S WOODRUFF AVE
IDAHO FALLS ID
83401-4322
US

IV. Provider business mailing address

333 S WOODRUFF AVE
IDAHO FALLS ID
83401-4322
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-2160
  • Fax: 208-552-8079
Mailing address:
  • Phone: 208-523-2160
  • Fax: 208-552-8079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberD3728
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: