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General NPI Number Information
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NPI Number | 1720585680
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Entity Type | Organization
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Legal Business Name | BLACKWELL DENTAL PLLC
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Dates
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Enumeration Date | 04/09/2018
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Last Update Date | 12/03/2020
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Provider Practice Location Address
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Address Line | 387 MAIN ST S
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City | WOODBURY
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State | CT
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Zip | 06798-3412
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Country | US
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Telephone | 757-581-9965
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Fax |
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Provider Business Mailing Address
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Address Line | 100 PLEASANT DR
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City | SOUTHBURY
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State | CT
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Zip | 06488-3231
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Country | US
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Telephone | 757-581-9965
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER/GENERAL DENTIST
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Name | DR. ANDREW NICHOLAS BLACKWELL
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Credential | DMD
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Telephone | 757-581-9965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 11-610
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License Number State | CT
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