Provider Demographics
NPI:1427099233
Name:DEREK R BLACKWELDER DMD PLLC
Entity type:Organization
Organization Name:DEREK R BLACKWELDER DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACKWELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-528-1212
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:944 LACONIA ROAD
Mailing Address - City:WINNISQUAM
Mailing Address - State:NH
Mailing Address - Zip Code:03289-1020
Mailing Address - Country:US
Mailing Address - Phone:603-528-1212
Mailing Address - Fax:603-528-1320
Practice Address - Street 1:944 LACONIA ROAD
Practice Address - Street 2:
Practice Address - City:WINNISQUAM
Practice Address - State:NH
Practice Address - Zip Code:03289-1020
Practice Address - Country:US
Practice Address - Phone:603-528-1212
Practice Address - Fax:603-528-1320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30316266Medicaid
NH685235OtherUNITED CONCORDIA