Provider Demographics
NPI:1447350020
Name:BLACKWOOD, CLINTON T (DDS)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:T
Last Name:BLACKWOOD
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 1:715 E 3900 S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2182
Mailing Address - Country:US
Mailing Address - Phone:801-266-7737
Mailing Address - Fax:801-266-7767
Practice Address - Street 1:715 E 3900 S
Practice Address - Street 2:SUITE 104
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2182
Practice Address - Country:US
Practice Address - Phone:801-266-7737
Practice Address - Fax:801-266-7767
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5936346-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist