Organization
BLACKSTOCKDENTALCORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BURCH LEE BLACKSTOCK D.D.S. (DENTIST)
(619) 443-0444
Entity
Organization
Contact information
Practice address
12110 WOODSIDE AVE, LAKESIDE, CA 92040-3012
(619) 443-0444
(619) 443-0050
Mailing address
12110 WOODSIDE AVE., LAKESIDE, CA 92040-3012
(619) 443-0444
(619) 443-0050
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
42123
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
42123
DENTAL BOARD
CA
Enumeration date
05/25/2007
Last updated
02/10/2016
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