Provider Demographics
NPI:1669482808
Name:BLALOCK, KEITH ALLAN (DDS,MS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLAN
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12340 BANDERA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4574
Mailing Address - Country:US
Mailing Address - Phone:210-695-9996
Mailing Address - Fax:210-695-9566
Practice Address - Street 1:12340 BANDERA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4574
Practice Address - Country:US
Practice Address - Phone:210-695-9996
Practice Address - Fax:210-695-9566
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics