Provider Demographics
NPI:1053409490
Name:THE BLEVINS LEGACY DENTAL
Entity type:Organization
Organization Name:THE BLEVINS LEGACY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-886-7000
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-0459
Mailing Address - Country:US
Mailing Address - Phone:740-886-7000
Mailing Address - Fax:740-886-5518
Practice Address - Street 1:148 STATE ROUTE 775
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8839
Practice Address - Country:US
Practice Address - Phone:740-886-7000
Practice Address - Fax:740-886-5518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213861223G0001X
WV34841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty