Provider Demographics
NPI:1124510482
Name:BLANCO, DANIEL MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MARK
Last Name:BLANCO
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 1:4910 LONGFORD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-2159
Mailing Address - Country:US
Mailing Address - Phone:909-979-7756
Mailing Address - Fax:
Practice Address - Street 1:9912 CARMEL MOUNTAIN RD STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2808
Practice Address - Country:US
Practice Address - Phone:858-538-9182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1024961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice