Healthcare Provider Details

I. General information

NPI: 1881346740
Provider Name (Legal Business Name): BLAINE EDWARD GRIFFITHS IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 10/24/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 CHESTER AVE
CLEVELAND OH
44106-1666
US

IV. Provider business mailing address

3000 SOUTHWIND TRL
YOUNGSTOWN OH
44514-2880
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-8730
  • Fax:
Mailing address:
  • Phone: 513-240-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-027295
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: