Healthcare Provider Details

I. General information

NPI: 1689775546
Provider Name (Legal Business Name): BRUCE A. BLACKBURN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S DIXON RD
KOKOMO IN
46901-5073
US

IV. Provider business mailing address

200 S DIXON RD
KOKOMO IN
46901-5073
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-3015
  • Fax: 765-456-1825
Mailing address:
  • Phone: 765-456-3015
  • Fax: 765-456-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12007761A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: