MEDICARE: DR. KYLE Z BLACKER DDS

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	1223G0001X	General Practice Dentistry	2016019236	MO

General Provider Information

NPI Number	:	1104353788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE Z BLACKER DDS

Provider Business Mailing Address
First Line	:	11208 QUINCY AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64137-2504
Country	:	US
Telephone Number	:	816-763-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	11208 QUINCY AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64137-2504
Country	:	US
Telephone Number	:	816-763-8400
Fax Number	:

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

Provider Enumeration Date	:	05/15/2017
Last Update Date	:	05/15/2017

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