Healthcare Provider Details

I. General information

NPI: 1528596632
Provider Name (Legal Business Name): TRENTON MATTHEW BLAHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 06/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 KENTUCKY AVE
PLATTE CITY MO
64079-7628
US

IV. Provider business mailing address

2204 KENTUCKY AVE
PLATTE CITY MO
64079-7628
US

V. Phone/Fax

Practice location:
  • Phone: 816-858-2027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2017017278
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: