Provider Demographics
NPI:1639238561
Name:BLACKLEY, DAVID W (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:BLACKLEY
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 1:6430 BROOK PARK DR
Mailing Address - Street 2:#100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918
Mailing Address - Country:US
Mailing Address - Phone:719-268-9777
Mailing Address - Fax:
Practice Address - Street 1:6430 BROOK PARK DR
Practice Address - Street 2:#100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-268-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice