Healthcare Provider Details

I. General information

NPI: 1306550934
Provider Name (Legal Business Name): BLEU HUXFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 BUCHANAN BLVD STE 108
BOULDER CITY NV
89005-2130
US

IV. Provider business mailing address

806 BUCHANAN BLVD STE 108
BOULDER CITY NV
89005-2130
US

V. Phone/Fax

Practice location:
  • Phone: 702-293-0205
  • Fax:
Mailing address:
  • Phone: 702-293-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7719
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: