Provider Demographics
NPI:1194838755
Name:BRENT L BLAYLOCK DDS PA
Entity type:Organization
Organization Name:BRENT L BLAYLOCK DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LASHLEY
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-493-8036
Mailing Address - Street 1:3206 OLD CHAPEL HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3688
Mailing Address - Country:US
Mailing Address - Phone:919-493-8036
Mailing Address - Fax:919-493-6060
Practice Address - Street 1:3206 OLD CHAPEL HILL RD STE 300
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3688
Practice Address - Country:US
Practice Address - Phone:919-493-8036
Practice Address - Fax:919-493-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC49701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty