Provider Demographics
NPI:1144350026
Name:BLANCO-PADILLA, IVETTE (DMD)
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:BLANCO-PADILLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5462 WHITTLESEY BLVD APT 212
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2199
Mailing Address - Country:US
Mailing Address - Phone:910-568-9561
Mailing Address - Fax:
Practice Address - Street 1:8999 AIRBORNE DIVISION RD
Practice Address - Street 2:BLDG 3255
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR24141223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice