Healthcare Provider Details

I. General information

NPI: 1750376968
Provider Name (Legal Business Name): BLAKE J EDINGER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 10/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15397 STATE HIGHWAY 32
LAKEWOOD WI
54138
US

IV. Provider business mailing address

15954 RIVERS EDGE DR STE 304
HAYWARD WI
54843-7894
US

V. Phone/Fax

Practice location:
  • Phone: 715-276-6321
  • Fax:
Mailing address:
  • Phone: 715-634-2541
  • Fax: 715-634-2541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3874
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: