Provider Demographics
NPI:1801281241
Name:BLACKWELL, ANDREW NICHOLAS (DMD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:NICHOLAS
Last Name:BLACKWELL
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 1:100 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3231
Mailing Address - Country:US
Mailing Address - Phone:973-627-0896
Mailing Address - Fax:
Practice Address - Street 1:387 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3412
Practice Address - Country:US
Practice Address - Phone:203-263-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11-6101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice