Blake David McDonald

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

11622565-9921 Issued in UT

Practice address

4651 W 13400 S Ste 110
Riverton, UT 84096-6483

Phone

(801) 515-5858

NPI assigned

Apr 3, 2019

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• South Davis Pediatric Dentistry LLC

  • Pediatric Dentistry
  • Bountiful, UT
  • NPI 1841891462
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1554249600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1707350400000",
    "number": "1013479492",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11039 S RYAN PARK AVE",
            "city": "SANDY",
            "state": "UT",
            "postal_code": "840925205",
            "telephone_number": "425-941-0314"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4651 W 13400 S STE 110",
            "city": "RIVERTON",
            "state": "UT",
            "postal_code": "840966483",
            "telephone_number": "801-515-5858"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "59 W Pages Ln Ste 110",
            "address_purpose": "LOCATION",
            "city": "Bountiful",
            "state": "UT",
            "postal_code": "84010",
            "country_code": "US",
            "telephone_number": "801-294-8880",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MCDONALD",
        "first_name": "BLAKE",
        "middle_name": "DAVID",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-04-03",
        "last_updated": "2024-02-08",
        "certification_date": "2024-02-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "UT",
            "license": "11622565-9921",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kaitlyn Maxfield
• Richard G Maxwell, MD
• Grace Berry Maycock, C.S.W.
• Ryan James McAffee, D.D.S
• Candace McBride, APRN
• Travis McDonald, MD
• Amber Lee McElreath, CPCI
• Keely McGee, LCSW
• Allison McLeod, RD
• Aimee McPhie, ACMHC

• Pediatric Dentistry in Riverton, UT
• Providers in Riverton, UT by specialty
• Pediatric Dentistry in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 8, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.