Healthcare Provider Details

I. General information

NPI: 1942495320
Provider Name (Legal Business Name): DAVID PAUL BLACKBURN DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 S STATE ROUTE 291 STE A
INDEPENDENCE MO
64057-2657
US

IV. Provider business mailing address

3131 S. STATE ROUTE 291 SUITE A
INDEPENDENCE MO
64057
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-6006
  • Fax: 816-373-1840
Mailing address:
  • Phone: 816-373-6006
  • Fax: 816-373-1840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2015012810
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: