Provider Demographics
NPI:1730103045
Name:BLACKBURN, JAY H (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:H
Last Name:BLACKBURN
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 1:105 W. MERCHANT STREET
Mailing Address - Street 2:
Mailing Address - City:NEW BUFFALO
Mailing Address - State:MI
Mailing Address - Zip Code:49117-1813
Mailing Address - Country:US
Mailing Address - Phone:269-469-3140
Mailing Address - Fax:269-469-6182
Practice Address - Street 1:105 W. MERCHANT STREET
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1813
Practice Address - Country:US
Practice Address - Phone:269-469-3140
Practice Address - Fax:269-469-6182
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI135791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice