Provider Demographics
NPI:1356643308
Name:BLACKROCK DENTAL PARTNERS, PLLC
Entity Type:Organization
Organization Name:BLACKROCK DENTAL PARTNERS, PLLC
Other - Org Name:BLACKROCK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-232-5294
Mailing Address - Street 1:1606 E. CENTER ST.
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4007
Mailing Address - Country:US
Mailing Address - Phone:208-232-5294
Mailing Address - Fax:208-233-5188
Practice Address - Street 1:1606 E. CENTER ST.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4007
Practice Address - Country:US
Practice Address - Phone:208-232-5294
Practice Address - Fax:208-233-5188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty