Provider Demographics
NPI:1972735017
Name:BLACKWOOD, MICHAEL SHANAHAN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANAHAN
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:10000 FALLS RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-4103
Mailing Address - Country:US
Mailing Address - Phone:301-983-1096
Mailing Address - Fax:
Practice Address - Street 1:10000 FALLS RD
Practice Address - Street 2:SUITE 209
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-4103
Practice Address - Country:US
Practice Address - Phone:301-983-1096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076061223X0400X
DCDEN53741223X0400X
MD111871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics