Healthcare Provider Details

I. General information

NPI: 1386741239
Provider Name (Legal Business Name): JARED V BLOXHAM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 COLUMBIA PARK TRL STE 101
RICHLAND WA
99352-4770
US

IV. Provider business mailing address

1363 COLUMBIA PARK TRL STE 101
RICHLAND WA
99352-4770
US

V. Phone/Fax

Practice location:
  • Phone: 509-578-5770
  • Fax: 509-578-5774
Mailing address:
  • Phone: 509-578-5770
  • Fax: 509-578-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10135
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number10135
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: