=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194976332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY BLAINE ROBINSON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2008
-----------------------------------------------------
Last Update Date | 09/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BAFB DENTAL CLINIC OMS 1067 TWINING DR
-----------------------------------------------------
City | BARKSDALE AFB
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71110-2486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-456-2743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1067 TWINING DR
-----------------------------------------------------
City | BARKSDALE AFB
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71110-2486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-456-2743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D-4177
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DEN.00205712
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 6918
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------