Provider Demographics
NPI:1144439993
Name:W.R. BLACKWELDER D.D.S. , INC.
Entity type:Organization
Organization Name:W.R. BLACKWELDER D.D.S. , INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACKWELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-594-1758
Mailing Address - Street 1:19728 COLIMA RD
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-3210
Mailing Address - Country:US
Mailing Address - Phone:909-594-1758
Mailing Address - Fax:909-594-4158
Practice Address - Street 1:19728 COLIMA RD
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-3210
Practice Address - Country:US
Practice Address - Phone:909-594-1758
Practice Address - Fax:909-594-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental