Provider Demographics
NPI:1154306751
Name:BLACKMON, HARRY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:
Last Name:BLACKMON
Suffix:JR
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 1:500 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-3210
Mailing Address - Country:US
Mailing Address - Phone:843-479-4085
Mailing Address - Fax:843-479-8991
Practice Address - Street 1:500 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3210
Practice Address - Country:US
Practice Address - Phone:843-479-4085
Practice Address - Fax:843-479-8991
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC002392Medicaid