Provider Demographics
NPI:1558780775
Name:BLACKHURST, NINA A (DMD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:A
Last Name:BLACKHURST
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 1:1123 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-2835
Mailing Address - Country:US
Mailing Address - Phone:302-723-2403
Mailing Address - Fax:
Practice Address - Street 1:2200 ARCH ST STE 102
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103
Practice Address - Country:US
Practice Address - Phone:302-723-2403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0395851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice