Provider Demographics
NPI:1215289855
Name:JOHN BLANTON, D.D.S. A PROFESSIONAL DENTAL CORP.
Entity type:Organization
Organization Name:JOHN BLANTON, D.D.S. A PROFESSIONAL DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-559-6666
Mailing Address - Street 1:10730 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4933
Mailing Address - Country:US
Mailing Address - Phone:310-559-6666
Mailing Address - Fax:310-559-6853
Practice Address - Street 1:10730 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4933
Practice Address - Country:US
Practice Address - Phone:310-559-6666
Practice Address - Fax:310-559-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty