Provider Demographics
NPI:1720585680
Name:BLACKWELL DENTAL PLLC
Entity Type:Organization
Organization Name:BLACKWELL DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-581-9965
Mailing Address - Street 1:100 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3231
Mailing Address - Country:US
Mailing Address - Phone:757-581-9965
Mailing Address - Fax:
Practice Address - Street 1:387 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3412
Practice Address - Country:US
Practice Address - Phone:757-581-9965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11-610261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental