Provider Demographics
NPI:1215433685
Name:BLACKBURN, CALEB (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:CALEB
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8840 BLAKENEY PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6718
Mailing Address - Country:US
Mailing Address - Phone:704-716-9840
Mailing Address - Fax:
Practice Address - Street 1:8840 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6718
Practice Address - Country:US
Practice Address - Phone:704-716-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC110131223S0112X
TN73026204E00000X, 204E00000X
NC202500269204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty