Provider Demographics
NPI:1215474622
Name:BLANCHE, EARL JORDAN (DMD)
Entity type:Individual
Prefix:DR
First Name:EARL JORDAN
Middle Name:
Last Name:BLANCHE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:EARL
Other - Middle Name:JORDAN
Other - Last Name:BLANCHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:975 VIA BLAIRO
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-8253
Mailing Address - Country:US
Mailing Address - Phone:951-283-0518
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:951-283-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101128122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist