Provider Demographics
NPI:1700285434
Name:BLACKMORE, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:NY
Mailing Address - Zip Code:13660-3128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9133
Practice Address - Country:US
Practice Address - Phone:315-871-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028173124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist