Provider Demographics
NPI:1891215760
Name:BLACKBURN, RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:BLACKBURN
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 1:3532 HOWARD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3699
Mailing Address - Country:US
Mailing Address - Phone:562-596-7484
Mailing Address - Fax:
Practice Address - Street 1:3532 HOWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3699
Practice Address - Country:US
Practice Address - Phone:562-501-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104972122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist