Healthcare Provider Details

I. General information

NPI: 1386404812
Provider Name (Legal Business Name): CLAYTON BLACKWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 N BROAD ST
COLMAR PA
18915-9701
US

IV. Provider business mailing address

2406 N BROAD ST
COLMAR PA
18915-9701
US

V. Phone/Fax

Practice location:
  • Phone: 215-712-8895
  • Fax:
Mailing address:
  • Phone: 215-712-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS044613
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code125Q00000X
TaxonomyOral Medicine Dentistry
License NumberDS044613
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS044613
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: