Provider Demographics
NPI:1790981330
Name:JOHN WALTON BLACKMAN III DDS
Entity Type:Organization
Organization Name:JOHN WALTON BLACKMAN III DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:BLACKMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-760-9258
Mailing Address - Street 1:1409 H PLAZA WEST RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1418
Mailing Address - Country:US
Mailing Address - Phone:336-760-9258
Mailing Address - Fax:336-659-9258
Practice Address - Street 1:1409 H PLAZA WEST RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1418
Practice Address - Country:US
Practice Address - Phone:336-760-9258
Practice Address - Fax:336-659-9258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty