Provider Demographics
NPI:1104190594
Name:BEAU D BLANKENSHIP, DDS, PC
Entity Type:Organization
Organization Name:BEAU D BLANKENSHIP, DDS, PC
Other - Org Name:LAKELINE MALL FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-722-9274
Mailing Address - Street 1:1215 SLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6373
Mailing Address - Country:US
Mailing Address - Phone:210-722-9274
Mailing Address - Fax:512-335-7668
Practice Address - Street 1:11200 LAKELINE MALL DR
Practice Address - Street 2:#B1
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-1501
Practice Address - Country:US
Practice Address - Phone:512-448-4867
Practice Address - Fax:512-335-7668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181540911Medicaid