Provider Demographics
NPI:1134641095
Name:BLANCHARD, SCOTTY JR (DMD)
Entity Type:Individual
Prefix:
First Name:SCOTTY
Middle Name:
Last Name:BLANCHARD
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 ALICE ST STE B
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4578
Mailing Address - Country:US
Mailing Address - Phone:912-285-5967
Mailing Address - Fax:912-285-0762
Practice Address - Street 1:1601 ALICE ST STE B
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4578
Practice Address - Country:US
Practice Address - Phone:912-285-5967
Practice Address - Fax:912-285-0762
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0154631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty