Provider Demographics
NPI:1144387234
Name:BLACKSTOCK, BURCH LEE (DDS)
Entity Type:Individual
Prefix:
First Name:BURCH
Middle Name:LEE
Last Name:BLACKSTOCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BURCH
Other - Middle Name:LEE
Other - Last Name:BLACKSTOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:12110 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3012
Mailing Address - Country:US
Mailing Address - Phone:619-443-0444
Mailing Address - Fax:619-443-0050
Practice Address - Street 1:12110 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3012
Practice Address - Country:US
Practice Address - Phone:619-443-0444
Practice Address - Fax:619-443-0050
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA421231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42123OtherDENTAL BOARD