Basic Information
Provider Information
NPI: 1003804303
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLOXSON
FirstName: MICHELE
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 415 N GRAND AVE
Address2:  
City: PUEBLO
State: CO
PostalCode: 810033111
CountryCode: US
TelephoneNumber: 7195624461
FaxNumber: 7195847694
Practice Location
Address1: 4257 W 3RD ST
Address2:  
City: DAYTON
State: OH
PostalCode: 454171406
CountryCode: US
TelephoneNumber: 9372681665
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/11/2005
LastUpdateDate: 03/19/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X30-022714OHY Dental ProvidersDentistGeneral Practice
1223S0112X2901018969MIN Dental ProvidersDentistOral and Maxillofacial Surgery

ID Information
IDTypeStateIssuerDescription
38190832802001 DENTAL BLUEOTHER
88171MI01 COMMERCEOTHER
88123MI01 BAYSIDEOTHER
163583401 UNITED CONCORDIAOTHER
466704705MI MEDICAID
88096MI01 WADSWORTHOTHER
88170MI01 OUTER DRIVEOTHER
D80109501 BLUE CROSSOTHER


Home