Provider Demographics
NPI:1780632745
Name:BLACKWELL, CHAD RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:RICHARD
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S DOBSON RD
Mailing Address - Street 2:STE C-25
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5678
Mailing Address - Country:US
Mailing Address - Phone:480-726-8464
Mailing Address - Fax:480-726-8465
Practice Address - Street 1:600 S DOBSON RD
Practice Address - Street 2:STE C-25
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5678
Practice Address - Country:US
Practice Address - Phone:480-726-8464
Practice Address - Fax:480-726-8465
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice