Provider Demographics
NPI:1730249541
Name:BLYTHE, DAVID CROCKETT JR (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CROCKETT
Last Name:BLYTHE
Suffix:JR
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 1:401 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4617
Mailing Address - Country:US
Mailing Address - Phone:985-851-3710
Mailing Address - Fax:985-851-3711
Practice Address - Street 1:401 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4617
Practice Address - Country:US
Practice Address - Phone:985-851-3710
Practice Address - Fax:985-851-3711
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1823457Medicaid
LA1823457Medicaid
LAT19754Medicare UPIN