Provider Demographics
NPI:1437286580
Name:BLALOCK, BRIAN CHRIS (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:CHRIS
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:145 CEDAR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5103
Mailing Address - Country:US
Mailing Address - Phone:760-724-8891
Mailing Address - Fax:760-724-7950
Practice Address - Street 1:145 CEDAR RD
Practice Address - Street 2:SUITE B
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5103
Practice Address - Country:US
Practice Address - Phone:760-724-8891
Practice Address - Fax:760-724-7950
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA063471223S0112X
CAOMS231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery