MEDICARE: DR. RILEY DAVIS BLACKHURST DDS

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	DEN-DEN-LIC-19340	MT

General Provider Information

NPI Number	:	1497363402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RILEY DAVIS BLACKHURST DDS

Provider Business Mailing Address
First Line	:	4620 RATTLESNAKE DR
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-3019
Country	:	US
Telephone Number	:	208-697-2794
Fax Number	:

Provider Business Practice Location Address
First Line	:	935 SW HIGGINS AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1460
Country	:	US
Telephone Number	:	406-721-2686
Fax Number	:

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

Provider Enumeration Date	:	07/15/2020
Last Update Date	:	07/15/2020

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