Healthcare Provider Details

I. General information

NPI: 1730249541
Provider Name (Legal Business Name): DAVID CROCKETT BLYTHE JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 LIBERTY ST
HOUMA LA
70360-4617
US

IV. Provider business mailing address

401 LIBERTY ST
HOUMA LA
70360-4617
US

V. Phone/Fax

Practice location:
  • Phone: 985-851-3710
  • Fax: 985-851-3711
Mailing address:
  • Phone: 985-851-3710
  • Fax: 985-851-3711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2345
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: