Provider Demographics
NPI:1528108784
Name:BLACKHURST, RONALD J (DDS)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:BLACKHURST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 S 900 E STE 450
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-6016
Mailing Address - Country:US
Mailing Address - Phone:801-561-5212
Mailing Address - Fax:801-561-5239
Practice Address - Street 1:7001 S 900 E STE 450
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-6016
Practice Address - Country:US
Practice Address - Phone:801-561-5212
Practice Address - Fax:801-561-5239
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1362351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT136235OtherSTATE LICENSE