Provider Demographics
NPI:1366521817
Name:BLACKETT, DAVID S (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:BLACKETT
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:PO BOX D1
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-0600
Mailing Address - Country:US
Mailing Address - Phone:360-482-4000
Mailing Address - Fax:360-482-8427
Practice Address - Street 1:615 W. WALDRIP ST.
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-482-4000
Practice Address - Fax:360-482-8427
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000095881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5043393Medicaid