Blackstockdentalcorp

NPI #1417168881 in Lakeside, California

Provider Information

NPI Number: 1417168881
Entity Type: Organization
Organization Name: Blackstockdentalcorp
Primary Specialty: Dentist - General Practice
Enumeration Date: May 25, 2007
Last Updated: Feb 10, 2016

Practice Location

Address: 12110 WOODSIDE AVE
City: Lakeside
State: California
ZIP Code: 92040-3012
Phone: (619) 443-0444

Authorized Official

Name: BURCH LEE BLACKSTOCK, D.D.S.
Title: DENTIST
Phone: (619) 443-0444

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist - General Practice — General Practice	1223G0001X	Primary

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