Healthcare Provider Details

I. General information

NPI: 1891215760
Provider Name (Legal Business Name): RICHARD BLACKBURN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 HOWARD AVE STE 200
LOS ALAMITOS CA
90720-3699
US

IV. Provider business mailing address

3532 HOWARD AVE STE 200
LOS ALAMITOS CA
90720-3699
US

V. Phone/Fax

Practice location:
  • Phone: 562-501-3188
  • Fax:
Mailing address:
  • Phone: 562-596-7484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number104972
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number104972
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number104972
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104972
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number104972
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number104972
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number104972
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number104972
License Number StateCA
# 9
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number104972
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number104972
License Number StateCA
# 11
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number104972
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: