Provider Demographics
NPI:1881346740
Name:GRIFFITHS, BLAINE EDWARD IV
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:EDWARD
Last Name:GRIFFITHS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 SOUTHWIND TRL
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2880
Mailing Address - Country:US
Mailing Address - Phone:513-240-1919
Mailing Address - Fax:
Practice Address - Street 1:9601 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1666
Practice Address - Country:US
Practice Address - Phone:216-368-8730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30-0272951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program