1962575290 NPI number — DR. MICHAEL MARTIN BLACKMON DR DDS

Table of content: DR. MICHAEL MARTIN BLACKMON DR DDS (NPI 1962575290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962575290 NPI number — DR. MICHAEL MARTIN BLACKMON DR DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKMON
Provider First Name:
MICHAEL
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DR DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962575290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 FARM VIEW CT NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30165-2679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-346-6793
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 RED BUD RD NE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALHOUN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30701-1966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
762-538-2095
Provider Business Practice Location Address Fax Number:
762-538-2097
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN011797 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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