Provider Demographics
NPI:1205232204
Name:BLYSTONE, LEBROCK SHYNNEL (RDA)
Entity Type:Individual
Prefix:
First Name:LEBROCK
Middle Name:SHYNNEL
Last Name:BLYSTONE
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 LA RICA AVE
Mailing Address - Street 2:STE D
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3163
Mailing Address - Country:US
Mailing Address - Phone:626-430-9171
Mailing Address - Fax:
Practice Address - Street 1:4000 LA RICA AVE
Practice Address - Street 2:STE D
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3163
Practice Address - Country:US
Practice Address - Phone:626-430-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83522126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant