Active NPI
Blake Imam, DMD
- Dentist
- Meridian, ID
National Provider Identifier
1285040394
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- D-4604
- Practice address
- 317 W Cherry LN
Meridian, ID 83642-1608 - Phone
- (208) 888-2055
- Fax
- (208) 395-1017
- NPI assigned
- Jul 9, 2014
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | D-4604 | ID | Primary |
Addresses
Primary practice location
317 W Cherry LN
Meridian, ID 83642-1608
Mailing address
317 W Cherry LN
Meridian, ID 83642-1608
Phone (208) 888-2055
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160623000446 | ID | Order and Referring Only - Dentist | 6608167549 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1404864000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1404864000000",
"number": "1285040394",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "317 W CHERRY LN",
"city": "MERIDIAN",
"state": "ID",
"postal_code": "836421608",
"telephone_number": "208-888-2055",
"fax_number": "208-395-1017"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "317 W CHERRY LN",
"city": "MERIDIAN",
"state": "ID",
"postal_code": "836421608",
"telephone_number": "208-888-2055",
"fax_number": "208-395-1017"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IMAM",
"first_name": "BLAKE",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2014-07-09",
"last_updated": "2014-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "ID",
"license": "D-4604",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Meridian, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.