Provider Demographics
NPI:1063570679
Name:BLACKBURN, JEFFREY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:BLACKBURN
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 1:2500 EAST JOLLY ROAD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910
Mailing Address - Country:US
Mailing Address - Phone:517-393-8500
Mailing Address - Fax:517-393-8596
Practice Address - Street 1:2500 EAST JOLLY ROAD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910
Practice Address - Country:US
Practice Address - Phone:517-393-8500
Practice Address - Fax:517-393-8596
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist