Provider Demographics
NPI:1659438075
Name:BLACKBURN, PETER WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:BLACKBURN
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 1:1817 RUDDIMAN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3145
Mailing Address - Country:US
Mailing Address - Phone:231-744-2458
Mailing Address - Fax:231-744-3423
Practice Address - Street 1:1817 RUDDIMAN DR
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3145
Practice Address - Country:US
Practice Address - Phone:231-744-2458
Practice Address - Fax:231-744-3423
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010167691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice