Provider Demographics
NPI:1679699383
Name:BLANKENSHIP, SUSAN D (DMD INC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:DMD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35036 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1925
Mailing Address - Country:US
Mailing Address - Phone:727-446-4699
Mailing Address - Fax:727-771-6804
Practice Address - Street 1:35036 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1925
Practice Address - Country:US
Practice Address - Phone:727-446-4699
Practice Address - Fax:727-771-6804
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00139501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071201900Medicaid