Healthcare Provider Details

I. General information

NPI: 1184743601
Provider Name (Legal Business Name): STEPHANIE STANLEY BLACKWELDER R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 OLD GLENWOOD ROAD
MARION NC
28752-2405
US

IV. Provider business mailing address

PO BOX 2012
OLD FORT NC
28762-2012
US

V. Phone/Fax

Practice location:
  • Phone: 828-659-7810
  • Fax: 828-652-3310
Mailing address:
  • Phone: 828-659-7810
  • Fax: 828-652-3310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5302
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: