Provider Demographics
NPI:1841416229
Name:DOUGLAS G BLACKMORE
Entity Type:Organization
Organization Name:DOUGLAS G BLACKMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLACKMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-934-7707
Mailing Address - Street 1:1 PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-1829
Mailing Address - Country:US
Mailing Address - Phone:201-934-7707
Mailing Address - Fax:201-934-1954
Practice Address - Street 1:1 PLAZA LN
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1829
Practice Address - Country:US
Practice Address - Phone:201-934-7707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 015264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty