Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0221X | Pediatric Dentist | 11622565-9921 | UT |
NPI | 1013479492 |
---|---|
Provider Name | Blake David Mcdonald |
First Address | Sandy, UT 84092-5205 |
Second Address | San Diego, CA 92123-2758 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2019 |
Last Update Date | 01/06/2021 |