Provider Demographics
NPI:1689775546
Name:BLACKBURN, BRUCE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
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 1:200 S DIXON RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-5073
Mailing Address - Country:US
Mailing Address - Phone:765-456-3015
Mailing Address - Fax:765-456-1825
Practice Address - Street 1:200 S DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5073
Practice Address - Country:US
Practice Address - Phone:765-456-3015
Practice Address - Fax:765-456-1825
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007761A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice