Healthcare Provider Details

I. General information

NPI: 1710963822
Provider Name (Legal Business Name): ELDON GARRETT BLOCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32020 LITTLE BOSTON RD NE
KINGSTON WA
98346-9734
US

IV. Provider business mailing address

32020 LITTLE BOSTON RD NE
KINGSTON WA
98346-9734
US

V. Phone/Fax

Practice location:
  • Phone: 360-297-9658
  • Fax: 360-297-9614
Mailing address:
  • Phone: 360-297-9658
  • Fax: 360-297-9614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6959
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: