Provider Demographics
NPI:1821576901
Name:BLACKWELL, MACKENZIE JEAN (RDH)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:JEAN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 599
Mailing Address - Street 2:604 N. THOMAS ST
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970
Mailing Address - Country:US
Mailing Address - Phone:434-447-4464
Mailing Address - Fax:
Practice Address - Street 1:604 N. THOMAS ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970
Practice Address - Country:US
Practice Address - Phone:434-447-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207558124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist