Individual
SCOTT M BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
333 S WOODRUFF AVE, IDAHO FALLS, ID 83401-4322
(208) 523-2160
(208) 552-8079
Mailing address
333 S WOODRUFF AVE, IDAHO FALLS, ID 83401-4322
(208) 523-2160
(208) 552-8079
Taxonomy
Speciality
Code
Description
License number
State
1223P0106X
Oral and Maxillofacial Pathology Dentistry
Primary
D3728
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010143970
REGENCE BLUE SHIELD
ID
05
—
118557800
—
WY
01
—
1504752
UNITED CONCORDIA
ID
01
—
6I468
FEDERAL BLUE CROSS
ID
05
—
806657300
—
ID
05
—
806720800
—
ID
Enumeration date
02/12/2007
Last updated
10/15/2015
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