Provider Demographics
NPI:1780706887
Name:BLACKHURST, DAVID R (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:BLACKHURST
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 1:565 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2148
Mailing Address - Country:US
Mailing Address - Phone:801-756-7211
Mailing Address - Fax:
Practice Address - Street 1:565 E STATE RD
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2148
Practice Address - Country:US
Practice Address - Phone:801-756-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6288637-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice