MEDICARE: DR. GEORGE MAURY BLACKBURN D.M.D., F.A.G.D.

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	122300000X	Dentist	10496	TX

General Provider Information

NPI Number	:	1003870601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE MAURY BLACKBURN D.M.D., F.A.G.D.

Provider Business Mailing Address
First Line	:	12505 HYMEADOW DR
Second Line	:	SUITE 2D
City	:	AUSTIN
State	:	TX
Zip	:	78750-1867
Country	:	US
Telephone Number	:	512-258-3627
Fax Number	:	512-258-0755

Provider Business Practice Location Address
First Line	:	12505 HYMEADOW DR
Second Line	:	SUITE 2D
City	:	AUSTIN
State	:	TX
Zip	:	78750-1867
Country	:	US
Telephone Number	:	512-258-3627
Fax Number	:	512-258-0755

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

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	07/08/2007

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