Provider Demographics
NPI:1356424931
Name:BLAIR, LON E (DMD)
Entity type:Individual
Prefix:DR
First Name:LON
Middle Name:E
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:LON
Other - Middle Name:E
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:6540 EMERALD ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-376-2891
Mailing Address - Fax:208-376-2895
Practice Address - Street 1:6540 EMERALD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-376-2891
Practice Address - Fax:208-376-2895
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD17401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice