Provider Demographics
NPI:1376634337
Name:BLACKHURST, RICHARD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:BLACKHURST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3822
Mailing Address - Country:US
Mailing Address - Phone:801-321-4000
Mailing Address - Fax:801-355-9007
Practice Address - Street 1:754 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3822
Practice Address - Country:US
Practice Address - Phone:801-321-4000
Practice Address - Fax:801-355-9007
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist