Basic Information
| Provider Information | |||||||||
| NPI: | 1750376968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDINGER | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7156342541 | ||||||||
| Practice Location | |||||||||
| Address1: | 15397 STATE HIGHWAY 32 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152766321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 10/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 3874 | WI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 100065650 | 05 | WI | MEDICAID |