Basic Information
| Provider Information | |||||||||
| NPI: | 1154938520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKHURST | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 735 EXETER ST | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283271455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016691992 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | BLDG 4-1838 NORMANDY DR | ||||||||
| Address2: | |||||||||
| City: | APO | ||||||||
| State: | AA | ||||||||
| PostalCode: | 283077302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104326190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2020 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 11821131-9922 | UT | Y | Dental Providers | Dentist | General Practice |
No ID Information.