Healthcare Provider Details

I. General information

NPI: 1487645487
Provider Name (Legal Business Name): ERIC BLACKWOOD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501GARFIELD ST.
QUINTER KS
67752
US

IV. Provider business mailing address

7250 COUNTY ROAD AA
QUINTER KS
67752-6119
US

V. Phone/Fax

Practice location:
  • Phone: 785-754-2441
  • Fax: 785-754-2466
Mailing address:
  • Phone: 785-754-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60189
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier116736
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier1005597
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerDORAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: