Provider Demographics
NPI:1700992021
Name:BLACKWELDER, DAN STEVEN (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:STEVEN
Last Name:BLACKWELDER
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 1:13027 W. LINEBAUGH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4477
Mailing Address - Country:US
Mailing Address - Phone:813-855-8877
Mailing Address - Fax:813-855-3131
Practice Address - Street 1:13027 W. LINEBAUGH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4477
Practice Address - Country:US
Practice Address - Phone:813-855-8877
Practice Address - Fax:813-855-3131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL75401223G0001X
FL75401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice