Provider Demographics
NPI:1376635391
Name:BLICKENSTAFF, JAY MAYNARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MAYNARD
Last Name:BLICKENSTAFF
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 1:2 WAYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-3994
Mailing Address - Country:US
Mailing Address - Phone:301-733-9020
Mailing Address - Fax:301-733-0136
Practice Address - Street 1:2 WAYSIDE AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-3994
Practice Address - Country:US
Practice Address - Phone:301-733-9020
Practice Address - Fax:301-733-0136
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD9244122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist