Provider Demographics
NPI:1013179258
Name:BRYAN KEITH BLANKENSHIP DDS PA
Entity Type:Organization
Organization Name:BRYAN KEITH BLANKENSHIP DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-280-0070
Mailing Address - Street 1:5000 SAWGRASS VILLAGE CIR
Mailing Address - Street 2:SUITE 23
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5045
Mailing Address - Country:US
Mailing Address - Phone:904-280-0070
Mailing Address - Fax:904-280-0079
Practice Address - Street 1:5000 SAWGRASS VILLAGE CIR
Practice Address - Street 2:SUITE 23
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-5045
Practice Address - Country:US
Practice Address - Phone:904-280-0070
Practice Address - Fax:904-280-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL193344261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6494270001Medicare NSC