Active NPI
Burch Lee Blackstock, D.D.S
- General Practice Dentistry
- Lakeside, CA
National Provider Identifier
1144387234
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 42123
- Practice address
- 12110 Woodside Ave
Lakeside, CA 92040-3012 - Phone
- (619) 443-0444
- Fax
- (619) 443-0050
- NPI assigned
- Jan 2, 2007
- Last updated
- Apr 17, 2014
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 42123 | CA | Primary |
Addresses
Primary practice location
12110 Woodside Ave
Lakeside, CA 92040-3012
Mailing address
12110 Woodside Ave
Lakeside, CA 92040-3012
Phone (619) 443-0444
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 42123 | Other | CA | DENTAL BOARD |
Other names 1
- Burch Lee Blackstock
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 42123 | CA | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Blackstockdentalcorp | General Practice | Past | Accepting new patients |
| Arthur Santos DDS Corp | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- General Practice Dentistry
- Lakeside, CA
- NPI 1417168881
-
- Dental Clinic/Center
- Lakeside, CA
- NPI 1770940637
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1167696000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1397692800000",
"number": "1144387234",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12110 WOODSIDE AVE",
"city": "LAKESIDE",
"state": "CA",
"postal_code": "920403012",
"telephone_number": "619-443-0444",
"fax_number": "619-443-0050"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12110 WOODSIDE AVE",
"city": "LAKESIDE",
"state": "CA",
"postal_code": "920403012",
"telephone_number": "619-443-0444",
"fax_number": "619-443-0050"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BLACKSTOCK",
"first_name": "BURCH",
"middle_name": "LEE",
"credential": "D.D.S",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-02",
"last_updated": "2014-04-17",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "CA",
"license": "42123",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DENTAL BOARD",
"identifier": "42123",
"state": "CA"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "BURCH",
"last_name": "BLACKSTOCK",
"middle_name": "LEE",
"credential": "D.D.S.",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Lakeside, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.