Provider Demographics
NPI:1700866910
Name:BLACKMAN, RUSSELL SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:SCOTT
Last Name:BLACKMAN
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 1:16845 N 29TH AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3053
Mailing Address - Country:US
Mailing Address - Phone:602-866-0418
Mailing Address - Fax:602-862-1194
Practice Address - Street 1:16845 N 29TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3053
Practice Address - Country:US
Practice Address - Phone:602-866-0418
Practice Address - Fax:602-862-1194
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice