Basic Information
| Provider Information | |||||||||
| NPI: | 1003804303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOXSON | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | DDS | ||||||||
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| 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 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 03/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 2901018969 | MI | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X | 30-022714 | OH | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1635834 | 01 | UNITED CONCORDIA | OTHER | 88123MI | 01 | BAYSIDE | OTHER | D801095 | 01 | BLUE CROSS | OTHER | 88096MI | 01 | WADSWORTH | OTHER | 88170MI | 01 | OUTER DRIVE | OTHER | 88171MI | 01 | COMMERCE | OTHER | 381908328020 | 01 | DENTAL BLUE | OTHER | 4667047 | 05 | MI | MEDICAID |