Provider Demographics
NPI:1700209699
Name:BLACKSTONE DENTAL PLLC
Entity Type:Organization
Organization Name:BLACKSTONE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-278-0458
Mailing Address - Street 1:6710 S BLACKSTONE RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6072
Mailing Address - Country:US
Mailing Address - Phone:801-278-0458
Mailing Address - Fax:801-278-0460
Practice Address - Street 1:6710 S BLACKSTONE RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6072
Practice Address - Country:US
Practice Address - Phone:801-278-0458
Practice Address - Fax:801-278-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7386388-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty