Provider Demographics
NPI:1629017744
Name:BLACKMON, KEITH A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:BLACKMON
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 1:107 PROFESSIONAL LN
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-3875
Mailing Address - Country:US
Mailing Address - Phone:334-792-5711
Mailing Address - Fax:334-678-8157
Practice Address - Street 1:107 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3875
Practice Address - Country:US
Practice Address - Phone:334-792-5711
Practice Address - Fax:334-678-8157
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51502435OtherBCBS OF AL
AL51502435OtherBCBS OF AL