Provider Demographics
NPI:1982490397
Name:BLACKBURN WC DMD
Entity type:Organization
Organization Name:BLACKBURN WC DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:562-596-7484
Mailing Address - Street 1:3532 HOWARD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3532 HOWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3699
Practice Address - Country:US
Practice Address - Phone:562-596-7484
Practice Address - Fax:562-430-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty