=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003804303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE LYNN BLOXSON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2005
-----------------------------------------------------
Last Update Date | 03/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4257 W 3RD ST
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45417-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-268-1665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 N GRAND AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-562-4461
-----------------------------------------------------
Fax | 719-584-7694
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2901018969
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30-022714
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------