Provider Demographics
NPI:1962575290
Name:BLACKMON, MICHAEL MARTIN (DR DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARTIN
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:DR DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 FARM VIEW CT NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2679
Mailing Address - Country:US
Mailing Address - Phone:706-346-6793
Mailing Address - Fax:
Practice Address - Street 1:705 RED BUD RD NE STE A
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-1966
Practice Address - Country:US
Practice Address - Phone:762-538-2095
Practice Address - Fax:762-538-2097
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0117971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice