Provider Demographics
NPI:1326194580
Name:BLANCO, ROSA C (DMD)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:C
Last Name:BLANCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4369 EVANS TO LOCKS RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4099
Mailing Address - Country:US
Mailing Address - Phone:706-863-8198
Mailing Address - Fax:
Practice Address - Street 1:4369 EVANS TO LOCKS RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4099
Practice Address - Country:US
Practice Address - Phone:706-863-8198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry