Provider Demographics
NPI:1023668597
Name:BLACKHURST, ALEXIA LAUREN (DMD)
Entity type:Individual
Prefix:DR
First Name:ALEXIA
Middle Name:LAUREN
Last Name:BLACKHURST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ELDERBERRY CT
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-2131
Mailing Address - Country:US
Mailing Address - Phone:302-507-9089
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2803
Practice Address - Country:US
Practice Address - Phone:757-953-8635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist