Provider Demographics
NPI:1437579158
Name:BLACKBURN, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 FM 1463 #700
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-5763
Mailing Address - Country:US
Mailing Address - Phone:281-769-3095
Mailing Address - Fax:
Practice Address - Street 1:5215 FM 1463
Practice Address - Street 2:700
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494
Practice Address - Country:US
Practice Address - Phone:281-769-3095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX309041223X0400X
VA04420001971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics