| Blackstockdentalcorp | |
|
12110 Woodside Ave Lakeside CA 92040-3012 | |
| (619) 443-0444 | |
| (619) 443-0050 |
| Full Name | Blackstockdentalcorp |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 12110 Woodside Ave, Lakeside, California |
| Authorized Official Name and Position | Burch Lee Blackstock (DENTIST) |
| Authorized Official Contact | 6194430444 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Blackstockdentalcorp 12110 Woodside Ave. Lakeside CA 92040-3012 Ph: (619) 443-0444 | Blackstockdentalcorp 12110 Woodside Ave Lakeside CA 92040-3012 Ph: (619) 443-0444 |
| NPI Number | 1417168881 |
|---|---|
| Provider Enumeration Date | 05/25/2007 |
| Last Update Date | 02/10/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417168881 | NPI | - | NPPES |
| 42123 | Other | CA | DENTAL BOARD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 42123 (California) | Primary |
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