Provider Demographics
NPI:1154938520
Name:BLACKHURST, JACOB STEVEN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:STEVEN
Last Name:BLACKHURST
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 1:735 EXETER ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NC
Mailing Address - Zip Code:28327-1455
Mailing Address - Country:US
Mailing Address - Phone:801-669-1992
Mailing Address - Fax:
Practice Address - Street 1:BLDG 4-1838 NORMANDY DR
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:28307-7302
Practice Address - Country:US
Practice Address - Phone:910-432-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11821131-992122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist