Healthcare Provider Details

I. General information

NPI: 1982640751
Provider Name (Legal Business Name): BLAINE SMITH BATEMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N CENTER ST
AMERICAN FORK UT
84003-1630
US

IV. Provider business mailing address

218 N CENTER ST
AMERICAN FORK UT
84003-1630
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-9310
  • Fax: 801-763-8600
Mailing address:
  • Phone: 801-756-9310
  • Fax: 801-763-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number135578
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: