Provider Demographics
NPI:1215114467
Name:TUDOR, BLAIR JOHN III (DMD)
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:JOHN
Last Name:TUDOR
Suffix:III
Gender:M
Credentials:DMD
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Other - Credentials:
Mailing Address - Street 1:670 SUPERIOR CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6174
Mailing Address - Country:US
Mailing Address - Phone:541-779-6170
Mailing Address - Fax:541-779-0989
Practice Address - Street 1:670 SUPERIOR CT
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6174
Practice Address - Country:US
Practice Address - Phone:541-779-6170
Practice Address - Fax:541-779-0989
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORD8994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist