Provider Demographics
NPI:1669712303
Name:BLACKWELL, BRIAN E (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:BLACKWELL
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 WOODLANE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1920
Mailing Address - Country:US
Mailing Address - Phone:651-738-8204
Mailing Address - Fax:
Practice Address - Street 1:2145 WOODLANE DR STE 104
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55125-1920
Practice Address - Country:US
Practice Address - Phone:651-738-8204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-17
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND132591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice