Provider Demographics
NPI:1992155568
Name:BLOMSTEDT, JEFF (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:BLOMSTEDT
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 1:4015 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-2901
Mailing Address - Country:US
Mailing Address - Phone:308-737-0684
Mailing Address - Fax:
Practice Address - Street 1:1510 E 20TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9033
Practice Address - Country:US
Practice Address - Phone:505-327-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4520122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist