Healthcare Provider Details

I. General information

NPI: 1215433685
Provider Name (Legal Business Name): CALEB BLACKBURN DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 BLAKENEY PROFESSIONAL DR
CHARLOTTE NC
28277-6718
US

IV. Provider business mailing address

8840 BLAKENEY PROFESSIONAL DR
CHARLOTTE NC
28277-6718
US

V. Phone/Fax

Practice location:
  • Phone: 704-716-9840
  • Fax:
Mailing address:
  • Phone: 704-716-9840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11013
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number73026
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number202500269
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: