Provider Demographics
NPI:1679089239
Name:BLAINE D. AUSTIN DDS INC.
Entity type:Organization
Organization Name:BLAINE D. AUSTIN DDS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORAL MAXILLO-FACIAL SURGERY
Authorized Official - Prefix:
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-759-4378
Mailing Address - Street 1:1250 E 3900 S STE 210
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1367
Mailing Address - Country:US
Mailing Address - Phone:801-265-1500
Mailing Address - Fax:801-259-9963
Practice Address - Street 1:1250 EAST 3900 SOUTH
Practice Address - Street 2:SUITE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-264-1500
Practice Address - Fax:801-265-9963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1409581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000005310Medicaid