MEDICARE: GEORGE M. BLACKBURN JR. D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	10496	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1003870601	OTHER	TX	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1083995500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE M. BLACKBURN JR. D.M.D.

Provider Business Mailing Address
First Line	:	12505 HYMEADOW DR
Second Line	:	STE. 2 D
City	:	AUSTIN
State	:	TX
Zip	:	78750-1867
Country	:	US
Telephone Number	:	512-258-3627
Fax Number	:

Provider Business Practice Location Address
First Line	:	12505 HYMEADOW DR
Second Line	:	STE. 2 D
City	:	AUSTIN
State	:	TX
Zip	:	78750-1867
Country	:	US
Telephone Number	:	512-258-3627
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GEORGE M. BLACKBURN
Credential	:	D.M.D.
Telephone Number	:	512-258-3627

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	08/30/2011

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