Provider Demographics
NPI:1790909349
Name:BLACKMUN, MARILYN (PDHAP)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:
Last Name:BLACKMUN
Suffix:
Gender:F
Credentials:PDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 SAN GORGONIO RD
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1352
Mailing Address - Country:US
Mailing Address - Phone:818-957-1589
Mailing Address - Fax:818-957-1589
Practice Address - Street 1:2209 SAN GORGONIO RD
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-1352
Practice Address - Country:US
Practice Address - Phone:818-957-1589
Practice Address - Fax:818-957-1589
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP11124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28993701Medicaid
CA133068OtherDELTA DENTAL INS