MEDICARE: BLACKER FAMILY DENTAL LLC

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

General Provider Information

NPI Number	:	1518742675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKER FAMILY DENTAL LLC

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	:	816-765-8403

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	:	816-765-8403

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SONJA WELLS
Credential	:
Telephone Number	:	816-763-8400

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	08/28/2023

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