Provider Demographics
NPI:1427047083
Name:BLACKISTON, BENJAMIN T (DMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:T
Last Name:BLACKISTON
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 1:3309 CUMMINGS HWY
Mailing Address - Street 2:SUITE F
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37419-2360
Mailing Address - Country:US
Mailing Address - Phone:423-821-3279
Mailing Address - Fax:423-821-1620
Practice Address - Street 1:3309 CUMMINGS HWY
Practice Address - Street 2:SUITE F
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37419-2360
Practice Address - Country:US
Practice Address - Phone:423-821-3279
Practice Address - Fax:423-821-1620
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000076321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice