Healthcare Provider Details

I. General information

NPI: 1821422908
Provider Name (Legal Business Name): ALONZO CARLOS BLACKMON D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 FORT WADE RD STE 100
PONTE VEDRA FL
32081-5205
US

IV. Provider business mailing address

153 FORT WADE RD STE 100
PONTE VEDRA FL
32081-5205
US

V. Phone/Fax

Practice location:
  • Phone: 904-395-5501
  • Fax:
Mailing address:
  • Phone: 904-395-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414082
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN23627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: