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General NPI Number Information
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NPI Number | 1437356029
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Entity Type | Individual
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Provider Name | THOMAS LAGRAND BLAISDELL D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/28/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1916 ELLIS AVE
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City | CALDWELL
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State | ID
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Zip | 83605-4811
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Country | US
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Telephone | 208-459-2376
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Fax | 208-459-1524
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Provider Business Mailing Address
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Address Line | 416 LARKSPUR CT
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City | CALDWELL
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State | ID
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Zip | 83605-6294
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Country | US
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Telephone | 208-402-4302
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D4079
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License Number State | ID
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