MEDICARE: DR. ERIC BLACKWOOD 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	60189	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	116736	OTHER	KS	BLUE CROSS BLUE SHIELD
2	1005597	OTHER	KS	DORAL

General Provider Information

NPI Number	:	1487645487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC BLACKWOOD DDS

Provider Business Mailing Address
First Line	:	7250 COUNTY ROAD AA
Second Line	:
City	:	QUINTER
State	:	KS
Zip	:	67752-6119
Country	:	US
Telephone Number	:	785-754-2252
Fax Number	:

Provider Business Practice Location Address
First Line	:	501GARFIELD ST.
Second Line	:
City	:	QUINTER
State	:	KS
Zip	:	67752
Country	:	US
Telephone Number	:	785-754-2441
Fax Number	:	785-754-2466

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/09/2007

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