Healthcare Provider Details

I. General information

NPI: 1669446258
Provider Name (Legal Business Name): BLAINE DONALD AUSTIN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5742 S 1475 E SUITE 100
OGDEN UT
84403
US

IV. Provider business mailing address

5742 S 1475 E SUITE 100
OGDEN UT
84403-4855
US

V. Phone/Fax

Practice location:
  • Phone: 801-399-3701
  • Fax: 801-399-3702
Mailing address:
  • Phone: 801-399-3701
  • Fax: 801-399-3702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number140958
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: