Scott M Blake, DDS

Primary specialty

Oral and Maxillofacial Pathology DentistryTaxonomy code 1223P0106X

License

D3728 Issued in ID

Practice address

333 S Woodruff Ave
Idaho Falls, ID 83401-4322

Phone

(208) 523-2160

Fax

(208) 552-8079

NPI assigned

Feb 12, 2007

Last updated

Oct 15, 2015By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 6

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: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1171238400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1444867200000",
    "number": "1376684175",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "333 S WOODRUFF AVE",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834014322",
            "telephone_number": "208-523-2160",
            "fax_number": "208-552-8079"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "333 S WOODRUFF AVE",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834014322",
            "telephone_number": "208-523-2160",
            "fax_number": "208-552-8079"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLAKE",
        "first_name": "SCOTT",
        "middle_name": "M",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-02-12",
        "last_updated": "2015-10-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0106X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Pathology",
            "state": "ID",
            "license": "D3728",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD",
            "identifier": "000010143970",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806720800",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FEDERAL BLUE CROSS",
            "identifier": "6I468",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806657300",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "118557800",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "1504752",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Cory Blad, LMSW
• Blair K. Garner, PA
• Kevin Blair, LMT,PTA
• Rebecca Nygaard Blair, RBT
• Victoria L Blair, NURSE PRACTITIONER
• Leslee Elyse Blanch, RD
• Lesli Blanchard, NNP
• Douglas U. Blank, MD
• Richard Alan Blatter, D.O.
• Anna Blonquist, NP-C

• Oral and Maxillofacial Pathology Dentistry in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Oral and Maxillofacial Pathology Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2015; 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.

Verify at the official NPI Registry.