Provider Demographics
NPI:1760401913
Name:BLACKBURN, JEFFERSON THAIR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:THAIR
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 1:1907 GILDENBOROUGH CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6051
Mailing Address - Country:US
Mailing Address - Phone:804-378-7539
Mailing Address - Fax:
Practice Address - Street 1:2301 ROBIOUS STATION CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2124
Practice Address - Country:US
Practice Address - Phone:804-378-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA6533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist