Provider Demographics
NPI:1386741239
Name:BLOXHAM, JARED V (DDS)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:V
Last Name:BLOXHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 COLUMBIA PARK TRL STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4770
Mailing Address - Country:US
Mailing Address - Phone:509-578-5770
Mailing Address - Fax:509-578-5774
Practice Address - Street 1:1363 COLUMBIA PARK TRL STE 101
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4770
Practice Address - Country:US
Practice Address - Phone:509-578-5770
Practice Address - Fax:509-578-5774
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049150Medicaid