Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 18595 | MT |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 18595 | MT |
NPI | 1063875946 |
---|---|
Provider Name | Joshua Blanton-Dickens |
First Address | Kalispell, MT 59901-1218 |
Second Address | Kalispell, MT 59901-1218 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2016 |
Last Update Date | 16/08/2021 |