Provider Demographics
NPI:1417235870
Name:BLACKWELL, HALEIGH STIDHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:HALEIGH
Middle Name:STIDHAM
Last Name:BLACKWELL
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 1:3145 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-5256
Mailing Address - Country:US
Mailing Address - Phone:205-835-9800
Mailing Address - Fax:
Practice Address - Street 1:3145 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-5256
Practice Address - Country:US
Practice Address - Phone:205-835-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist