Provider Demographics
NPI:1548475551
Name:BLACKHURST, ROBERT REESE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:REESE
Last Name:BLACKHURST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 N 2000 W
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4047
Mailing Address - Country:US
Mailing Address - Phone:801-763-5555
Mailing Address - Fax:801-763-8984
Practice Address - Street 1:922 N 2000 W
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4047
Practice Address - Country:US
Practice Address - Phone:801-763-5555
Practice Address - Fax:801-763-8984
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT359932-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice