MEDICARE: DR. BENJAMIN T BLACKISTON DMD

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	1223G0001X	General Practice Dentistry	DS0000007632	TN

General Provider Information

NPI Number	:	1427047083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENJAMIN T BLACKISTON DMD

Provider Business Mailing Address
First Line	:	3309 CUMMINGS HWY
Second Line	:	SUITE F
City	:	CHATTANOOGA
State	:	TN
Zip	:	37419-2360
Country	:	US
Telephone Number	:	423-821-3279
Fax Number	:	423-821-1620

Provider Business Practice Location Address
First Line	:	3309 CUMMINGS HWY
Second Line	:	SUITE F
City	:	CHATTANOOGA
State	:	TN
Zip	:	37419-2360
Country	:	US
Telephone Number	:	423-821-3279
Fax Number	:	423-821-1620

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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