MEDICARE: BLASINGAME DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1508624222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLASINGAME DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	384 HARTNELL AVE STE A
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96002-1884
Country	:	US
Telephone Number	:	530-241-3302
Fax Number	:	530-241-3321

Provider Business Practice Location Address
First Line	:	4545 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5257
Country	:	US
Telephone Number	:	530-241-3302
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE BILLING COORDINATOR
Name	:	MICHELLE PETERS
Credential	:
Telephone Number	:	530-241-3302

Provider Enumeration Date	:	03/07/2024
Last Update Date	:	03/07/2024

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