Provider Demographics
NPI:1891907614
Name:BLACKMON, LAWRENCE BURNETT (DDS)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:BURNETT
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69730 HIGHWAY 111
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2869
Mailing Address - Country:US
Mailing Address - Phone:760-321-8869
Mailing Address - Fax:760-324-9929
Practice Address - Street 1:69730 HIGHWAY 111
Practice Address - Street 2:SUITE 105
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2869
Practice Address - Country:US
Practice Address - Phone:760-321-8869
Practice Address - Fax:760-324-9929
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38041122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist