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General NPI Number Information
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NPI Number | 1629483987
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Entity Type | Organization
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Legal Business Name | BLAIR PEDIATRIC DENTISTRY PC
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Dates
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Enumeration Date | 06/25/2014
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Last Update Date | 06/25/2014
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Provider Practice Location Address
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Address Line | 5360 N EAGLE RD SUITE 103
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City | BOISE
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State | ID
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Zip | 83713-4901
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Country | US
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Telephone | 208-938-9958
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Fax |
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Provider Business Mailing Address
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Address Line | 5360 N EAGLE RD SUITE 103
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City | BOISE
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State | ID
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Zip | 83713-4901
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Country | US
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Telephone | 208-938-9958
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RANDALL P BLAIR
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Credential | DMD
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Telephone | 702-485-9804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D4550PD
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License Number State | ID
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