Provider Demographics
NPI:1386952240
Name:BLACKHART, SCOTT PARKER (DMD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:PARKER
Last Name:BLACKHART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 W F ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3502
Mailing Address - Country:US
Mailing Address - Phone:209-847-0309
Mailing Address - Fax:209-847-2391
Practice Address - Street 1:1419 W F ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3502
Practice Address - Country:US
Practice Address - Phone:209-847-0309
Practice Address - Fax:209-847-2391
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist