Provider Demographics
NPI:1770909707
Name:BLACKMON, ADRIEN (DA)
Entity type:Individual
Prefix:
First Name:ADRIEN
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 BROOKWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:WALESKA
Mailing Address - State:GA
Mailing Address - Zip Code:30183-3175
Mailing Address - Country:US
Mailing Address - Phone:404-735-2030
Mailing Address - Fax:
Practice Address - Street 1:12420 CUMMING HWY
Practice Address - Street 2:STE 306
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7568
Practice Address - Country:US
Practice Address - Phone:678-947-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant