Provider Demographics
NPI:1063637668
Name:BLACKMAN, JOHN WALTON II (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTON
Last Name:BLACKMAN
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1409 PLAZA WEST ROAD
Mailing Address - Street 2:SUITE H
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-760-9258
Mailing Address - Fax:336-659-9258
Practice Address - Street 1:1409 PLAZA WEST ROAD
Practice Address - Street 2:#H
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-760-9258
Practice Address - Fax:336-659-9258
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC3165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist